Victorian Heights Income and Asset Survey
Please print and fill out
Prospective tenant need only show means to substantiate a one year rental fee.
Assets Trusts

Residence, estimated market value
$______________Mortgaged:____Yes ____No
Balance owed $_______________________
Vacation or second home: $__________________
Mortgaged:____Yes Balance $________________
Other land or buildings estimated market value:
$______________________Mortgaged:______
If so, balance owed $______________________

Stocks, current market value $_______________

Bonds_________________$_______________

Mutual Funds____________$_______________

Money Markets__________$_______________

Certificates of Deposit_____$________________

IRAs__________________$________________

Savings Account_________$________________

Checking Account________$________________

Annuities-redeemable value_$________________

Partnership or business_____$_______________
(value of your interest)
Notes, land contracts,_____$________________
and mortgages you hold

Trusts, value of principle: $_______________

Are you the benificiary of a trust? ___Y___N

Who is the trustee?____________________
Can you recieve the principal?___Yes ___No
How?_______________________________
____________________________________
____________________________________
Will you ever be the full legal owner of the
principal? ____Yes ____No
How and when?_______________________
____________________________________
____________________________________

Is the trust revocable ___Yes ___No

Other Assets: $______________________

TOTAL ASSETS $_____________________

Income:
Please calculate your monthly income

Social Security____________$_____________
Pension_________________$_____________
Annuity Income___________$_____________
Trust Income_____________$_____________
Rental Income____________$_____________
Other___________________$_____________
TOTAL MONTHLY INCOME $____________

All of the information proved on this entire form will be kept strictly confidential.
Mail to:
Victorian Heights Assisted Living, 1537 US Highway 2, Crystal Falls, MI 49920