Please Complete One Application Per Person

APPLICATIONFORRESIDENCY

Villa St. Francisdoesnotdiscriminateon thebasisofrace,color,creed,sex,nationalorigin,handicaporveteran'sstatus.

Please complete one application per person.

Applicant:(Mrs.MissMs.Mr.Rev.)______

FirstNameMiddleInitialLastName

Address:______

CityStateZip Code

PhoneNumber:(__) ______DateofBirth:.______

MaritalStatus:SiSingle Married Widowed DivorcedGender: Female Male

Social Security#: ______Medicare #:______

Applicant'scurrentlivingarrangements: o Apartment Home/Condo Withfamily NursingHome Other

Hospital Preference: ______Race:______

Physician Name:______Phone: ______Fax:______

Dentist Name: ______Phone:______Fax:______

Primary Contact: POA HC Activated: Yes No Durable POA Guardian

(AttachcopiesofPOAforHealthCareFinance)

Name: ______Relationship:______

Address:______

CityStateZip Code email

Home Phone#:______Business Phone #______Cell Phone#______

2ndContact: POA HC Activated: Yes No Durable POA Guardian

(AttachcopiesofPOAforHealthCareFinance)

Name:______Relationship:______

Address:______

CityStateZip Code email

Home Phone#:______Business Phone #______Cell Phone#______

Bills Will Be Sent To:

Name:______Relationship:______

Address:______

CityStateZip Code

Home Phone#:______Business Phone #______Cell Phone#______

HealthInsurance:(Attach copies of Medicare card & Insurance cards with application.)

SUPPLEMENTAL HEALTH INSURANCE:

Company Name: ______Phone:______

Address: ______City, State, Zip Code:______

Policy#______Group#______

Is this policy in your name? Yes NoSpouse’s Name: ______

Does policy cover

prescriptions?: Yes No

ADDITIONAL INSURANCE PLANS: (i.e. Long-Term Care or Dental?MEDICARE D DRUG COVERAGE:

Company Name: ______Organization Name: ______

Address: ______Plan Name: ______

City, State, Zip: ______I.D. Number: ______

Policy #______Group#______Attach copies of insurance cards to application

Where do you get your prescriptions? VA ______Mail Order ______Local Pharmacy______

Please list name of establishment where you are obtaining your prescriptions ______

RELIGION / AFFILIATION

Religion: ______Congregation/Synagogue: ______

Address: ______City, State, Zip: ______

Pastor: ______Phone #:______

FUNERAL HOME:

Name: ______Address: ______

City, State, Zip: ______Phone #______

Yearly Income:·

Social Security: / $
Pension (type of): / $
$
Interest from stocks, bonds, CD’s, dividends, etc:. / $
Trust Insurance:
Annuity:
Other (pleaseexplain): / $

Assets:

Stocks,bonds,etc. / $
Cash(SavingsChecking): / $
Real-Estate (estimated Fair Market Value): / $
FundsinTrust: / $
Other (pleaseexplain): / $

Yearly Expenses:

Mortgage/Rent:
Social Security:. / $
Insurance: / $
Loans: / $
Taxes: / $
Medical Expenses (including medicine) / $
Living Expenses (food, transportation,utilities, etc.): / $
Other (please explain): / $

Hasthere been anysaleofhouseorpropertyortransferofassetsinthelastthree(5)years?Yeso No

If yes, please explain: ______

______

DoyouhaveaBurialTrust?o Yeso NoAmount: $______

LegalInformation:

I hereby attest that all personal and financial information I have furnished on this application is true and accurate to the best of my knowledge. I understand that this information is strictly confidential and will be used by Villa St. Francis to help determine my eligibility for residency.

I have included a $300.00 application fee. I understand that if I am accepted for residency and choose not to come, this fee will not be refunded. If I am not accepted for residency, the fee will be refunded.

______

Applicant/Responsible Party Signature Date

Villa St. Francis Application for ResidencyPage 1 of 31910 W. Ohio Ave. Milwaukee, WI 53215

Office:(414) 649-2888

May 2012Fax: (414) 649-2880