Name:
Email:

Applicant:

Address:
Street/P.O. Box: City: State: Zip:

Telephone: U.S. Citizen: Yes No

Type of Accommodation Desired: -- Please Select One -- Private Deluxe Private Shared Room

Briefly describe present condition of health
(include significant medical diagnosis and/or physical limitations)
Present condition of health:

Are you receiving any assistance at home at this time? Yes No

If yes, briefly describe:
Type of assistance you are receiving at home (if any):

Social Security Number:

Medicare Number:

Medicaid Number:

Other Insurance:

Prescription Card: Yes No

Name of Physician:

Address:
Physician's Address:

Telephone:

Hospital of Choice:

Funeral Home:

Address:
Funeral Home Address:

Phone:

Person to notify in case of emergency
Name:

Address:

Telephone Work:

Home:

Next of Kin
Name: Address: Telephone: Relationship:

A. Cash Assets

Bank: Location:

Checking Acct. #
Balance in Account:

Savings Acct. #
Balance in Account:

Certificates of Deposit? Yes No
Approximate Amount

B. REAL ESTATE ASSETS

Applicant Own Home? Yes No
Approximate Value

Does applicant own any other property? Yes No
Approximate Value

Does applicant receive any rental income? Yes No

How much?
Per month
Per Year

C. Life Insurance Cash Value

Does applicant have life insurance policies with cash value? Yes No

Approximate Cash Value

Annuities
Company Name

Have you established a pre-paid burial fund? Yes No
What is the value

D. Securities

Does applicant have stocks and bonds? Yes No

Approximate Value of All Securities

E. Other Income

Social Security Check
Disability Check

Pension
Annuity
Other

Person Assisting with Finances

Name: Relationship:

Address:

Telephone
Work: Home:

Does this person have Power of Attorney? Yes No

Everything stated in this application is true and correct. I also understand that Eden Heights considers this application as a continuing statement of financial condition and agree to notify Eden Heights of any substantial change in the above financial condition. All of this information will be kept strictly confidential by Eden Heights.

I agree disagree with the above statement

Eden Heights accepts all residents without regard to race, creed, color, marital status, national origin, age, sex, sexual preference, blindness, disability, or sponsor.

3030 Clinton Street
West Seneca, NY 14224
716-822-4466
Fax 716-822-5107