THE ACTORS FUND HOMES
APPLICATION FOR ADMISSIONDate______
NURSING HOME______ASSISTED LIVING______
I. GENERAL INFORMATION CONCERNING PROSPECTIVE APPLICANT:
A. Applicant’s Name______Home Telephone______
Birth Date______Age______Place of Birth (county/state)______
Home Address______
City______County______State/Zip______
Marital Status______Religion______Church______
Spouse/equivalent name______
Father’s Name______Mother’s Maiden Name______
Previous Occupation______Military Service______
Referred to The Actors’ Fund Homes by______
Applicant is now at __ home __ hospital __ nursing home __other (specify)______
Has the applicant been admitted to a hospital within the last 6 months? Yes______No______
If yes, please list the hospital name______
Has the applicant ever been in another nursing center?Yes______No______
If yes, please list the nursing center and dates of stay______
Is the applicant aware of the placement decision?Yes______No______
Personal physician’s name______
Address______
Telephone______
Will the applicant’s personal physician attend here?Yes______No______
B. Eligibility:
Please provide attached eligibility guidelines prior to filling out this section.
SELF: Professional Name______
Legal Name (if different from above)______
Entertainment Occupation______
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RELATIVE: Name______
Entertainment Occupation______
Relationship to Applicant______SS#______
Address______
Telephone #______
C. Union Affiliation(s) of Eligible Professional (with dates joined):
Parent Union______Date______
Others______Date______
______Date______
______Date______
D. Professional Engagements of Eligible Professional (in chronological order):
Dates/ProductionLocationRole/Position
______
______
______
______
______
______
______
______
______
______
______
______
First Professional Performance/Date______
Last Professional Performance/Date______
Please provide supporting documentation to verify entertainment industry earnings of at least $2,000.00 for ten out of the twenty years. (Example: W-2 forms, pay stubs, union printouts, etc.)
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E. Individual Responsible for Paying Bills:
Name______Relationship to applicant______
Home Address______
City______State/Zip______
Telephone - Home ______Business______
F. Power of Attorney:
Has anyone been appointed Power of Attorney or Guardian?Yes______No______
If so, who?______
To what extent?______
Has an advance directive been prepared?Yes______No______
Type______
G. Additional Relatives (significant others):
Name______Relationship to Applicant______
Home Address______
City______State/Zip______
Telephone – Home______Business______
Name______Relationship to Applicant______
Home Address______
City______State/Zip______
Telephone – Home______Business______
II.FINANCIAL INFORMATON CONCERNING APPLICANT
To qualify financially, all questions must be answered as completely and accurately as possible.
Social Security #______
Medicare #______Date______Part A __ Part B
Medigap #______Medicare Supplemental Insurance______
Prescription Card______Policy #______
Long Term Care Insurance______Policy #______
Other Insurance______Policy #______
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A. Monthly Income
Recipient’s NameMonthly Amount
Social Security______$______
Civil Service Retirement______$______
V.A. Pension______$______
Military Retirement______$______
Railroad Retirement______$______
Rental/Income______$______
Residuals/Royalties______$______
Pensions______$______
Other (specify)______$______
B. Cash Assets in Banks, Credit Unions, Savings and Financial Institutions
Institution Name______Location______
Type of Account______Balance in Account $______
Names Listed on Account______
Institution Name______Location______
Type of Account______Balance in Account $______
Names Listed on Account______
Institution Name______Location______
Type of Account______Balance in Account $______
Names Listed on Account______
Institution Name______Location______
Type of Account______Balance in Account $______
Names Listed on Account______
C. Real Estate Assets
Does the applicant own their home?Yes__No__Approximate Value $______
Is the property owned jointly?Yes__ No__
Name(s) of co-owners______
Does the applicant own any additional property? Yes__ No__ Approximate Value $______
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D. License Insurance Cash Value
Does the applicant have life insurance policies with cash value?Yes___ No___
Company Name______
Approximate cash value $______Annuities $______
E. Funeral Arrangements
Has the applicant made pre-paid funeral arrangements?Yes___ No ___
Funeral Home/Cremation preference (name)______
Telephone #______Burial Account Amount______
F. Other Assets/Investments (CD, stocks, bonds, IRA’s)
Company Name______Approximate value $______
Company Name______Approximate value $______
Company Name______Approximate value $______
Company Name______Approximate value $______
G. Medicaid/Title XIX (19)
Has the applicant applied, or will the applicant shortly be applying for Medicaid Assistance?
Yes___ No___Medicaid #______
If the applicant has applied, what was the date?______County/State______
Dept. of Social Services representative______Telephone #______
I hereby certify that to the best of my knowledge and belief, the above stated information is true and complete. I understand that if any information has been falsely represented, this will be sufficient for voiding my application for admission. All of the information will be kept confidential by The Actors’ Fund Homes.
I hereby authorize The Actors’ Fund Homes to seek verification from financial institutions, employers, or union affiliations regarding my financial status or work history and to contact any other agency or individual for information.
Signature of Applicant______Date______
Signature of Sponsor/Guarantor______Date______
The Actors’ Fund Homes’ Representative______Date______
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