Cherry Ridge Memory Care Application

All information will be held confidential

NOTE: All fields with an asterisk (*) are required

Name * First Last
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone * - (###) - ### ####
Date of Birth * / MM / DD YYYY
Email *
Marital Status Single Married Divorced Widowed
Number of Children
Anniversary Date
Name of Spouse *
Date of Birth * / MM / DD YYYY
Power of Attorney (if applicable) *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Person to notify in case of emergency *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone * - (###) - ### ####
Email *
What was/is your occupation?
Spouse
What are your hobbies or interests?
Spouse
Driver's License #
Will you be bringing a car? Yes No
If so, please provide plate #
Apartment/Cottage size desired *
Location/Floor desired *
Are you capable of independent living without help from anyone else? * Yes No
Medicare # (1st Person) *
Medicare # (2nd Person) *
Supplemental Health Insurance
Insurer *
Policy No. *
Please give name, address, and telephone number of primary physician.
Name First Last
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - (###) - ### ####
Have you guaranteed any debt owed by another? * Yes No
Guarantor 1 *
Guarantor 2 *
Guarantor 3 *
Guarantor 4 *
Debtor 1 *
Debtor 2 *
Debtor 3 *
Debtor 4 *
Relation 1 *
Relation 2 *
Relation 3 *
Relation 4 *
Amount of Debt Guaranteed 1 *
Amount of Debt Guaranteed 2 *
Amount of Debt Guaranteed 3 *
Amount of Debt Guaranteed 4 *
Regular Monthly Income- Applicant
Social Security * $ . Dollars Cents
Pension * $ . Dollars Cents
Dividends * $ . Dollars Cents
Interest * $ . Dollars Cents
Mortgage/Rental Income * $ . Dollars Cents
IRA Income * $ . Dollars Cents
Trust Income * $ . Dollars Cents
Other * $ . Dollars Cents
Total Regular Monthly Income * $ . Dollars Cents
Regular Monthly Income- Spouse
Social Security * $ . Dollars Cents
Pension* * $ . Dollars Cents
Dividends * $ . Dollars Cents
Interest * $ . Dollars Cents
Mortgage/Rental Income * $ . Dollars Cents
IRA Income * $ . Dollars Cents
Trust Income * $ . Dollars Cents
Other * $ . Dollars Cents
Total Regular Monthly Income * $ . Dollars Cents
*With regard to monthly pension income reflected, will the monthly payment continue in the same amount for the life of the other person listed (generally, the surviving spouse)? * Yes No
If no, what will the monthly payment be after the death of the recipient listed?
I hereby declare that all statements made herein are true according to my best knowledge and belief. In witness whereof, I have hereunto set my hand to this application. * Yes
Date * / MM / DD YYYY
Financial Statement

(Must be completed by each individual; joint holdings must be so noted) ALL INFORMATION WILL BE HELD CONFIDENTIAL
Assets of *
Cash
1st person * $ . Dollars Cents
Is the asset security for a loan? * Yes No
2nd person * $ . Dollars Cents
Is the asset security for a loan? * Yes No
CD's Money Markets
1st person * $ . Dollars Cents
Is the asset security for a loan? * Yes No
2nd person * $ . Dollars Cents
Is the asset security for a loan? * Yes No
Stocks & Bonds
1st person * $ . Dollars Cents
Is the asset security for a loan? * Yes No
2nd person * $ . Dollars Cents
Is the asset security for a loan? * Yes No
IRA's Annuities, etc.
1st person * $ . Dollars Cents
Is the asset security for a loan? * Yes No
2nd person * $ . Dollars Cents
Is the asset security for a loan? * Yes No
House
1st person * $ . Dollars Cents
Is the asset security for a loan? * Yes No
2nd person * $ . Dollars Cents
Is the asset security for a loan? * Yes No
Other Real Estate
1st person * $ . Dollars Cents
Is the asset security for a loan? * Yes No
2nd person * $ . Dollars Cents
Is the asset security for a loan? * Yes No
Trust Fund (Indicate % of beneficial int.)
1st person * $ . Dollars Cents
Is the asset security for a loan? * Yes No
2nd person * $ . Dollars Cents
Is the asset security for a loan? * Yes No
Cash Surrender Value of Life Insurance
1st person * $ . Dollars Cents
Is the asset security for a loan? * Yes No
2nd person * $ . Dollars Cents
Is the asset security for a loan? * Yes No
Other Assets (describe below) *
1st person * $ . Dollars Cents
Is the asset security for a loan? * Yes No
2nd person * $ . Dollars Cents
Is the asset security for a loan? * Yes No
Total Assets
1st person * $ . Dollars Cents
2nd person * $ . Dollars Cents

Cherry Ridge Memory Care Application

Cherry Ridge Memory Care Application

Supplemental Health Insurance

Please give name, address, and telephone number of primary physician.

Regular Monthly Income- Applicant

Regular Monthly Income- Spouse

Financial Statement (Must be completed by each individual; joint holdings must be so noted) ALL INFORMATION WILL BE HELD CONFIDENTIAL

Cash

CD's Money Markets

Stocks & Bonds

IRA's Annuities, etc.

House

Other Real Estate

Trust Fund (Indicate % of beneficial int.)

Cash Surrender Value of Life Insurance

Total Assets

Financial Statement

(Must be completed by each individual; joint holdings must be so noted) ALL INFORMATION WILL BE HELD CONFIDENTIAL