Application for Residency

Thank you for your interest in Kingsway. In order to properly process an individual's application, we must have the following information. Please answer all questions carefully. The information herein is confidential and constitutes the basis for resident/tenant acceptance

Name of Applicant

U.S. Citizen?

Residency Details

Type of Residence Desired

Independent Living

Assisted Living

Skilled Nursing/Rehab

Other Details

Attending Physician

Health Coverage

Individuals to be contacted for future correspondence

Please fill out the following correspondence information.

Correspondence One

Authorized to assist with finances?

Correspondence Two

Authorized to assist with finances?

Confidential Financial Statement

List up to three (3) assets you intend to use to pay for you care, i.e. bank/investment accounts

Asset One

Asset Two

Asset Three

Do you have any CDs?

Do you own stocks or bonds?

Do you own real estate?

Do you plan to sell principal residence or other real estate to pay for your financial obligations while at Kingsway?

Have you created a Trust or have any of your assets been transferred within the last 5 years?

I understand that the Kingsway Community relies upon the accuracy of the above information for the purpose of determining whether there will be a source of payment and to determine when the resident may need financial assistance.

I hereby give Kingsway Community permission to verify medical and financial information supplied on this application for admission and further agree that the funds will be available for the care of the applicant during his/her residency at the Kingsway Community.