This form must be completed and returned to the Admission Coordinator prior to consideration for admission.

I)

Name of applicant:

Telephone:

Current Location

Birth Date

Gender:

Religion:

Social Security #:

Medicare #:

BC/BS #:

Other insurance:

Marital status:

Spouse’s name:

Mother’s name:

Father’s name:

Birthplace:

Citizenship:

Attending physician:

Funeral director:

Family/Responsible Party/POA:

Home Phone:

Work Phone:

Other family:

Home Phone:

Work Phone:

Other family:

Home Phone:

Work Phone:

FINANCIAL STATEMENT

II) Resources – Please list current dollar amounts to the nearest hundred.

ASSETS:

1) CHECKING ACCOUNTS:

A.

Bank Name/Telephone #:

Account #:

Current Balance:

B.

Bank Name/Telephone #:

Account #:

Current Balance:

C.

Bank Name/Telephone #:

Account #:

Current Balance:

2) SAVINGS ACCOUNTS:

A.

Bank Name/Telephone #:

Account #:

Current Balance:

B.

Bank Name/Telephone #:

Account #:

Current Balance:

C.

Bank Name/Telephone #:

Account #:

Current Balance:

3) CERTIFICATES OF DEPOSIT:

A.

Bank Name/Telephone #:

Account #:

Current Balance:

B.

Bank Name/Telephone #:

Account #:

Current Balance:

C.

Bank Name/Telephone #:

Account #:

Current Balance:

4) STOCKS, MUTUAL FUNDS AND BONDS:

A.

Name of Security:

Company/Broker Name & Telephone Number:

# of Shares:

Current Value:

B.

Name of Security:

Company/Broker Name & Telephone Number:

# of Shares:

Current Value:

C.

Name of Security:

Company/Broker Name & Telephone Number:

# of Shares:

Current Value:

5) Insurance Policies:

A.

Name of Company/Agent Telephone Number:

Type of Policy:

Current Value:

B.

Name of Company/Agent Telephone Number:

Type of Policy:

Current Value:

C.

Name of Company/Agent Telephone Number:

Type of Policy:

Current Value:

5) REAL ESTATE ASSETS:

A.

Current Value:

B.

Current Value:

C.

Current Value:

7) OTHER ASSETS:

A.

Description:

Current Value:

B.

Description:

Current Value:

C.

Description:

Current Value:

8)ASSET TRANSFERS (Attach additional sheet, if necessary)

Explain any and all transfers of your Assets that you, your Power of Attorney or any other individual made on your behalf, within five (5) years of the date that you complete this application. ASSETS include, but are not limited to, cash, certificates of deposit, gifts, stocks, and bonds, real estate, collectibles, etc.

A.

Asset Description:

Date of Transaction:

To Whom Transferred:

Asset Value:

B.

Asset Description:

Date of Transaction:

To Whom Transferred:

Asset Value:

C.

Asset Description:

Date of Transaction:

To Whom Transferred:

Asset Value:

D.

Asset Description:

Date of Transaction:

To Whom Transferred:

Asset Value:

E.

Asset Description:

Date of Transaction:

To Whom Transferred:

Asset Value:

F.

Asset Description:

Date of Transaction:

To Whom Transferred:

Asset Value:

9) MONTHLY INCOME:

Pension/Retirement

Source:

Amount:

Social Security

Source:

Amount:

Other: (Rental Income, Annuity Payments, Trusts, Interest or Dividends from Investments

Source:

Amount:

10) LIABILITIES: (MORTGAGE, CREDIT CARDS, LOANS, NOTES, TAXES, LIENS, OTHER DEBTS)

A.

Payable To:

Amount Owed:

B.

Payable To:

Amount Owed:

C.

Payable To:

Amount Owed:

D.

Payable To:

Amount Owed:

E.

Payable To:

Amount Owed:

F.

Payable To:

Amount Owed:

Have any trusts been created by the applicant in the past 60 months? If yes, please provide details:

I CERTIFY THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS ACCURATE TO THE BEST OF MY KNOWLEDGE.

Signature

Reset

Federal and State law prohibit this facility from denying admission to anyone because of race, creed, age, sex, color, blindness, national origin, disability, marital status, sponsor or sexual preference.

Admission Application

I)

FINANCIAL STATEMENT

II) Resources – Please list current dollar amounts to the nearest hundred.

ASSETS:

1) CHECKING ACCOUNTS:

2) SAVINGS ACCOUNTS:

3) CERTIFICATES OF DEPOSIT:

4) STOCKS, MUTUAL FUNDS AND BONDS:

5) Insurance Policies:

5) REAL ESTATE ASSETS:

7) OTHER ASSETS:

8)ASSET TRANSFERS (Attach additional sheet, if necessary)

9) MONTHLY INCOME:

10) LIABILITIES: (MORTGAGE, CREDIT CARDS, LOANS, NOTES, TAXES, LIENS, OTHER DEBTS)

We are fully accredited by the State of New York, and we maintain a reputation as one of the finest long-term care facilities in Western NY.