Financial application

Transcription

1 Financial application The following information is gathered to assist us in reviewing your application and planning for your future residency. Couples (or co-applicants) should complete one set of forms jointly. Please fill out all items as completely as possible. If there are any items that do not pertain to you, please mark as Not Applicable (N/A). This information will be held in the strictest confidence. NAME (person 1): of Birth: Social Security #: NAME (person 2): of Birth: Social Security #: LIFESTYLE OF INTEREST Independent Living Personal Care or Assisted Living Memory Care Post-Acute Care (Short-Term Rehab) Long-Term Care (Skilled Nursing) COMMUNITY OF INTEREST Buffalo Valley Lutheran Village 189 E. Tressler Boulevard, Lewisburg, PA Cumberland Crossings 1 Longsdorf Way, Carlisle, PA Diakon Senior Living Hagerstown Ravenwood, 1183 Luther Drive, Hagerstown, MD Robinwood, Tranquility Circle, Hagerstown, MD Frey Village 1020 North Union Street, Middletown, PA LONG-TERM CARE INSUR ANCE* Please describe the provisions of your long-term care insurance policy. Long-Term Care Insurance* Person 1 Person 2 Benefit period (indicate the number of years or record L for lifetime) Elimination period (i.e., record the number of days from 0 to 365 before benefit payments start) Luther Crest 800 Hausman Road, Allentown, PA The Lutheran Home at Topton One South Home Avenue, Topton, PA Manatawny Manor 30 Old Schuylkill Road, Pottstown, PA Ohesson 276 Green Avenue, Lewistown, PA Twining Village 280 Middle Holland Road, Holland, PA Daily benefit for assisted living in current dollars Daily benefit for nursing care in current dollars Assumed inflation rate on benefit payment *If you are applying for Personal Care/Assisted Living or Long-Term Care and wish Diakon to consider the LTC policy benefit as income, please attach letter from insurance company about benefits to be paid. 1 of 6

2 ASSETS: REAL ESTATE Please provide information for real estate that does not generate income (income-generating real estate must be recorded on the Other Assets form, on page 3 of this document). For Owner s Name, list first name of owner; for couples, enter joint if owned jointly. The Net Value is the estimated sale price today minus any mortgage and/ or home equity loans and expected selling costs. Visit for a quick estimate or ask us to do this for you. The is the amount that is to go to the surviving spouse. Real Estate (including primary residence) Address, City, Zip Owner s Name Net Value Primary residence (other than CCRC) Other NON-incomegenerating real estate (please describe): Do you have life use of any property? ASSETS: SAVINGS, STOCKS, BONDS, INVESTMENTS It is preferable to record totals for stocks and bonds rather than listing all individual accounts. Description Owner s Name Current Market Value Income and Dividends Checking/Savings/CDs Total - Please attach front page of latest bank statement(s). Stocks/Bonds Total Please attach front page of last month s brokerage statement(s). ASSETS: LIFE INSUR ANCE Please provide information in which your spouse (or co-applicant) has been designated as a beneficiary. Do not record life insurance policies in which your spouse (co-applicant) is NOT listed as a beneficiary. Life Insurance Type of Policy Owner s Name Death Benefit (minus any loans) Policy #1 Policy #2 Policy #3 2 of 6

3 ASSETS: OTHER ASSETS, SUCH AS INCOME-GENER ATING REAL ESTATE For Net Value, record your estimate of the market value minus any outstanding obligations and costs of disposing of or selling the asset. In the Began column, record when payment began or if unknown, record NOW. In the Ends column, record month and year when payments end, or record L if lifetime. Description Owner s Name Net Value Annual Income Is Income Taxable? Began Ends If a Trust is listed, do you have access to the Principal held in Trust? Notes: ASSET TR ANSFERS This applies to all gifting of assets, not any sales for market value. Please list any and all transfers of assets (property, funds, other valuables) over the past five years. Asset Market Value Transferred To Amount Received INCOME: SOCIAL SECURITY Social Security Are you currently receiving social security income? Monthly Income Owner s Name If not, when do you plan to begin drawing social security? Person 1 Person 2 INCOME: SOCIAL SECURITY DISABILITY Social Security Are you currently receiving social security disability? Amount Person 1 Person 2 3 of 6

4 INCOME: PENSIONS AND ANNUITIES In the Began column, record when payment began or if unknown, record NOW. In the Ends column, record month and year when payments end, or record L if lifetime. Pensions and Annuities Description Owner s Name Monthly Income Began Ends Does income adjust for inflation? Pension Pension Annuity Annuity INCOME: IR AS, 401(K) PLANS AND ROTH IR AS In the Balance area, record the balance that corresponds to your as of date, or most current balance available. In the Draw area, record the income draw and circle your response for number of draws per year. IRAs, 401(k) Plans, Roth IRAs Description Owner s Name Balance/Draw Are you taking from it now? Began Ends IRA - is it Roth? IRA - is it Roth? 401(k) 401(k) 4 of 6

5 INCOME: OTHER INCOME ONLY Please provide information regarding other income for which you do not own any portion of the asset, such as alimony. Description Owner s Name Monthly Income Ends Does income adjust for inflation? Is income taxable? TRUSTEE(S): If you listed a Trust Income anywhere on this form, please provide the following information: Trustee Name: Phone: Trustee Name: Phone: Name of the bank or institution administering the Trust: TOTAL LIABILITIES: Please list any debts, obligations, mortgages, reverse mortgages, credit cards, etc., that may affect the above assets or income. Person 1: Person 2: Total Liabilities: 5 of 6

6 MONTHLY EXPENSES: INDEPENDENT LIVING/PERSONAL CARE/ASSISTED LIVING ONLY Please record your personal monthly expenses. Do not include monthly fees (if you are currently a resident of Diakon), long-term care insurance premiums or income taxes. All expenses should be recorded as monthly amounts; if you have annual expenses, divide by 12 and record that amount. Monthly Expenses Person 1 Person 2 Prescriptions and other medical costs Meals (that are not included in the monthly fee of a Diakon Resident) Utilities Travel, entertainment and club memberships Personal items and clothing Automobile expenses Insurance premiums, excluding LTC insurance Rent, condo fees, mortgage payments Property and personal taxes Home maintenance/repairs/housekeeping/landscaping Other (describe): Other (describe): ATTESTATION: The above financial information is valid and truthful to the best of my knowledge. I understand that upon the offer of occupancy, additional current financial information may be required. Signature: : Signature: : I understand that prior to any change in residency level, a clinical and financial evaluation is required to determine clinical and financial appropriateness for admission to a new residency level. Signature: : Signature: : 6 of 6 Diakon Senior Living Diakon1 Diakon does not discriminate in admissions, the provision of services, or referrals of clients on the basis of race, color, religious creed, disability, marital status, ancestry, national origin, sexual orientation, age or sex.