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 property manager 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, please 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:
Comment:

Applicant Information

	Applicant(s) Name	Relation	Social Security No.	Date of Birth
1.
2.

How can we contact you for additional information if needed?

Contact Name:
Home Phone:
Work Phone:
Cell Phone:
Email Address:

Gross Annual Income For Each Applicant

	Wages	Self Employment	Social Security SSI Pension Disability Workers Comp. Veterans Benefits	Public Assistance	Other; e.g. 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?