Applicant

Diagnosis
First Name
Middle Name
Last Name
Address Line 1
Address Line 2
City
State
Zip Code
Date of Birth
Age
Gender	Male Female
Marital Status
Religion/Race
Social Security Number
Veterans Status
Medicare Number
Medicaid Number
Admitted From

Responsible Party

First Name
Last Name
Relationship to the Applicant
Address Line 1
Address Line 2
City
State
Zip
Email Address
Home Phone
Work Phone
Cell Phone

Additional Information

Power of Attorney/Living Will
Education
Occupation
Place of Birth/Citizenship
Is the patient aware of the placement?	yes no
Attending Physician
Allergies
Mortuary Name
Mortuary Phone
Laundry	yes no
Secondary Insurance Name
Secondary Insurance ID Number
Comments
Application Date
Admission Date
Admission Location
Admission Type
Patient Number

Financial Questionnaire

Applicant First Name
Last Name
Income (enter monthly amounts)
Social Security
Pension
VA Pension
Dividends and Interest
Other (rental, land contract, etc.)
Assets
Checking Account(s) Balance
Checking Account Name
Checking Account Address
Savings Account(s) Balance
Savings Account Name
Savings Account Address
CD and Other Securities Balance
Savings Bonds Balance
Stocks and Bonds Balance
Cash on Hand (home, safety deposit box)
Have any assets been sold/transferred/disposed in last 5 years?	yes no
Real Estate
Does the applicant own real estate?	yes no
Location
Approximate Value of the Property
Are there liens or judgements against the property?	yes no
Does the applicant own rental property?	yes no
If yes, list name and address

Life Insurance

Company Name
Policy Number
Face Value
Cash Surrender Value
Beneficiary
Other funds set aside for burial?	yes no If yes, specify:
Prepaid burial?	yes no
If yes, specify the amount and funeral home
Does any party other than the applicant have access and control of the aforementioned assets?	yes no
If yes, specify name and address

_________________________

I hereby acknowledge that the information as provided herein is correct. Failure to disclose accurate financial information may be grounds for legal action in accordance with prevailing Federal, State, and Local Statutes and regulations. *