* = Required Information

Please indicate below the amount of INCOME you receive from each of the following sources and the frequency of Income received (weekly, monthly, quarterly, annually).

Source of Income

Social Security

Supplemental Security

Interest Income

Dividend Income

Pension

Annuity

Support from Relatives

Other

Other

Please indicate below the approximate market value of each of the following assets you own:

ASSETS

Cash - Checking Account

VALUE IN DOLLARS

Cash - Savings Account

VALUE IN DOLLARS

Certificate of Deposit

VALUE IN DOLLARS

Securities - Stocks / Bonds / Mutual Funds

VALUE IN DOLLARS

Notes & Contracts Receivable

VALUE IN DOLLARS

Life Insurance (Cash Surrender Value)

VALUE IN DOLLARS

Personal Property (Auto, Jewelry, etc.)

VALUE IN DOLLARS

Retirement Funds (ex: IRA's, 401K)

VALUE IN DOLLARS

Real Estate (Market Value)

VALUE IN DOLLARS

Other Assets

VALUE IN DOLLARS

Other Assets

VALUE IN DOLLARS

LIABILITIES

Current Debt (Credit Cards, Accounts)

VALUE IN DOLLARS

Notes Payable

VALUE IN DOLLARS

Taxes Payable

VALUE IN DOLLARS

Real Estate Mortgages

VALUE IN DOLLARS

Other Liabilities

VALUE IN DOLLARS

Other Liabilities

VALUE IN DOLLARS

Total Liabilities

VALUE IN DOLLARS

Net Worth

VALUE IN DOLLARS

The financial information on this form is a true and correct statement of my current financial position to the best of my knowledge and belief. I further attest that U have not transferred, or donated, to another person's assets which are not reflected on this form within the past 5 years.


Please answer all questions as completely and accurately as possible. This information is important for admission to Groton Community Health Care Center, Inc. and will be held in the strictest confidence.

Male Female
Home Adult Home Nursing Home Hospital Other
Cortland Regional Medical Center Cayuga Medical Center Other

Please check source of payment below:

Private Payment:

The responsible party indicates adequate funds to pay for applicant's care for a period of at least months. This in no way infringes upon the applicant's right to apply and/or become eligible for third party payment.

Medicaid:

Other Long Term Care Insurance:

Please indicate the following Medicare information:

Yes No
Yes No
Yes No
Yes No

Additional Insurance Information:

Applicant Spouse

Telephone Number:

Power of Attorney/Person handling Finances/ Responsible Party for Payment

Telephone Number:

Telephone Number:

In compliance with New York State and Federal laws which prohibit discrimination based on race, creed, color, national origin, age, sex, marital status, sexual preference, blindness, source of payment or sponsorship, this facility admits and treats all residents on a non-discriminatory basis.

Completion and submission of this application does not ensure and/or guarantee admission.

This facility is Smoke Free, no resident smoking is allowed in the facility or on the grounds.

This completed form should be returned to Groton Community Health Care Center, Inc.



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