Residential Application - Cross Keys Village
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1
2R
L
A
ESIDENTIAL
IVING
PPLICATION
All information is confidential. Application must be completed in full to be processed. If not applicable,
please indicate N/A.
Name of Applicant:
Name of Co-Applicant:
Current Address:
(
)
City
State
Zip Code
Telephone and/or Cell #
Email Address: ___________________@_____________
Applicant’s Birth Date
Co-Applicant’s Birth Date:
Marital Status:
Anniversary Date:
Church Membership:
Pastor:
Address:
E
F
I
:
STIMATED
INANCIAL
NFORMATION
Total Monthly Income:
Social Security (Net):
$
Pension/Retirement:
$
Other Income (describe):
$
Assets:
Liabilities:
Real Estate:
$
Mortgage Balance: $
Investments: $
Other: $
Other:
$
Name of contact person other than applicants (ex. POA, family member, trust officer):
(
)
Name
Telephone
Address
City
State
Zip Code
Relationship
E-mail
Were you referred to us by a resident? No Yes: ___________________________________
Please print their name
Does applicant(s) have long term care insurance?
no yes
no yes
If yes, does it include a Personal Care facility benefit?
If yes, is the policy for applicant co-applicant both
K:\Marketing\COMMON BRAIN\PACKET INFO + FLOOR PLANS + PRICING\APPLICATION WORK\RL Application With Garden Homes Updated.doc
Revised July 2014
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