ADMISSION APPLICATION

MONTHLY INCOME
Enter the dollar amounts in the space provided.

Social Security$Social Security 
Pension(s) $Pension(s) 
Other $Other 

LIABILITIES
Enter the dollar amounts in the space provided.

Rent or Mortgage $Rent or Mortgage 
Credit Cards $Credit Cards 
Loans $Loans    
Other Debt $Other Debt

ASSETS
Enter the dollar amounts in the space provided.

Checking and Savings Account $Checking Savings 
Stocks and Bonds $Stock and Bonds 
Annuities $Annuities    
IRA's $IRA's
Life Insurance (Cash Value) $Life Insurance   
Your Home Value $Home Value 
Other Real Estate $Other Real Estate   
Other Monthly Assets $   Monthly total, if any   

INSURANCE INFORMATION
Enter the dollar amounts in the space provided.

Medicare Yes   No 
Medical AssistanceYes   No 
Medical Advantage Plan Yes   No;   if yes, provider:Provider Name   
Medicare Supplemental Insurance YesNo; if yes, provider:Provider Name
Prescription Drug Plan (or Medicare Part D) YesNo; if yes, provider:   Provider Name    
Private Health Insurance YesNo; if yes, provider:Provider Name
Long Term Care Insurance YesNo; if yes, provider: Provider Name