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PRELIMINARY APPLICANT INFORMATION

PRELIMINARY APPLICANT INFORMATION AND INCOME AND ASSET DISCLOSURE FOR THE ROSE AFFORDABLE SENIOR ASSISTED LIVING COMMUNITIES

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This Preliminary Applicant Information and Income and Asset Disclosure form will permit the property manager to screen your eligibility for residing at the property. More detailed information and verifications will be required prior to your actual approval for residency. This prescreening is intended to allow you and the administrator to recognize immediately any issues of income eligibility that exist. Your cooperation will facilitate the processing of your application and will avoid surprises later in the process. As you complete this form, do not hesitate to contact us with any questions.

Apply To:

Thank you for applying for residency in our affordable senior living community. Before you complete this form, please tell us how you learned about our property, including specific sources such as the specific newspaper ad or a particular referral person or organization:
Comment:

Applicant Information
Household Member No. Applicant(s) Name Relationship Are you 55 or older?
1.
2.

 

How can we contact you for additional information if needed?

Contact Name:
Home Phone:     Work Phone: Cell Phone:
Address:        
City:     State: Zip Code:
Email Address: 

GROSS ANNUAL INCOME
Household
Member
No.
Wages Self
Employment
Social Security
SSI
Pension
Disability
Workers Comp.
Veterans Benefits
Public
Assistance
Other;
for example
recurring
financial contributions
or gifts
1.
2.
Total

Assets and Other Income
Assets Cash Value* Actual Income from Asset
Cash on Hand
Checking Account
Savings Account
Safety Deposit Box
Certificates of Deposit
Money Market Funds
Stocks
Bonds
IRA Accounts
401 Accounts
Keogh Accounts
Trust Funds
  • Revocable
  • Irrevocable


Real Property, including home or rental property
Land Contracts, including Contracts for Deed or Mortgages
Lump Sum Receipts in last 2 years, including inheritance or personal injury receipts
Capital Investments
Life Insurance Policies (excluding term policies)
Other Retirement/Pension Funds not included above
Personal Property held as an investment; e.g. coin collections, art, antiques cars. Do not include necessary personal property
Other

*Cash value is defined as the market value minus the cost of converting the asset to cash. The cost of conversion includes such fees as broker´s fees, settlement costs, early withdrawal penalties, etc.

Yes No    Within the last two (2) years I/we have sold or given away assets (including cash, accounts, real estate, etc.) for less than the asset´s fair market value.
If yes, please list the assets below.

Asset Cash Value Value Received Date Disposed

Yes No    Are you on the Section 8 Housing Choice Voucher?

Yes No    Are you on the Elderly Waiver?

If so, who is your case manager?