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

First Name:

Middle Name:

Last Name:

U.S. Citizen?

Yes

No

If not a citizen of U.S. or dual citizenship, what country?:

Address: (Street, City, State, Zipcode)

Phone Number:

Residency Details

Type of Residence Desired

Independent Living

Village Apt - 1 Bedroom

Village Apt - 2 Bedroom

Parkland Garden Apt - 1 Bedroom

Parkland Garden Apt - 2 Bedroom

Kingsway Court Apt - 1 Bedroom

Assisted Living

Kingsway Manor

Skilled Nursing/Rehab

Kingsway Arms Nursing Center

Other Details

Desired Occupancy Date: (mm/dd/yyyy)

Present Living Arrangement:

Date of Birth: (mm/dd/yyyy)

Any additional information:

Male

Female

Marital Status:

Attending Physician

Name of Physician:

Phone Number:

Health Coverage

HMO/Other Insurance:

Health Information:

Group Number:

Medications:

Individuals to be contacted for future correspondence

Please fill out the following correspondence information.

Correspondence One

Name:

Home Number:

Work Number:

Address: (Street, City, State, Zipcode)

Relationship:

POA

Guardian

Health Care Proxy

Authorized to assist with finances?

Yes

No

Correspondence Two

Name:

Home Number:

Work Number:

Address: (Street, City, State, Zipcode)

Relationship:

POA

Guardian

Health Care Proxy

Authorized to assist with finances?

Yes

No

Confidential Financial Statement

Earned Income: (Monthly)

Social Security Benefits:

Veteran's Benefits:

Other Pension:

Railroad Retirement:

Annuity:

Other:

Net Monthly Income:

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

Asset One

Institution:

Address: (Street, City, State, Zipcode)

Asset Two

Institution:

Address: (Street, City, State, Zipcode)

Asset Three

Institution:

Address: (Street, City, State, Zipcode)

Do you have any CDs?

No

Yes

If yes, what is the value?

Do you own stocks or bonds?

No

Yes

If yes, what is the value?:

Do you own real estate?

No

Yes

If yes, what is the value?:

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

No

Yes

List any other assets:

List total assets available to pay for your care:

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

No

Yes

If yes, please provide information:

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.

Name of Prospective Resident:

Address:

Phone Number:

Name of Financially Responsible Party (if other than resident)?:

Relationship to Applicant:

I Agree