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
Support from Relatives
Please indicate below the approximate market value of each of the following assets you own:
Cash - Checking Account
VALUE IN DOLLARS
Cash - Savings Account
Certificate of Deposit
Securities - Stocks / Bonds / Mutual Funds
Notes & Contracts Receivable
Life Insurance (Cash Surrender Value)
Personal Property (Auto, Jewelry, etc.)
Retirement Funds (ex: IRA's, 401K)
Real Estate (Market Value)
Current Debt (Credit Cards, Accounts)
Real Estate Mortgages
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.
Please check source of payment below:
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.
Other Long Term Care Insurance:
Please indicate the following Medicare information:
Additional Insurance Information:
Power of Attorney/Person handling Finances/ Responsible Party for Payment
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.