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Admission Application

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

I)

FINANCIAL STATEMENT

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

 

ASSETS:

1) CHECKING ACCOUNTS:

A.

B.

C.

2) SAVINGS ACCOUNTS:

A.

B.

C.

3) CERTIFICATES OF DEPOSIT:

A.

B.

C.

4) STOCKS, MUTUAL FUNDS AND BONDS:

A.

B.

C.

5) Insurance Policies:

A.

B.

C.

5) REAL ESTATE ASSETS:

A.

B.

C.

7) OTHER ASSETS:

A.

B.

C.

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.

B.

C.

D.

E.

F.

9) MONTHLY INCOME:

Pension/Retirement

Social Security

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

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

A.

B.

C.

D.

E.

F.

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

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.