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2. 
3. Financial Checklist Prior to Admission (Form 1b)
5. This financial check list must be completed by responsible party and turned into the Administrative Assistant before admission.
7. Check the Yes or No to the following questions
9. 1. Social Security award letter (formerly TPQY), VA verification, RR verification, or ANY

   1. YES
   2. NO
11. 2. Income verification

    1. YES
    2. NO
13. 3. Medicare, Medicaid cards, verification what type of Medicaid, ie: spend down

    1. YES
    2. NO
15. 4. Current bank statement for checking and savings

    1. YES
    2. NO
17. 5. Copy of life insurance – verification of cash value

    1. YES
    2. NO
19. 6. Copy of irrevocable funeral trust

    1. YES
    2. NO
21. 7. Proof of assets, car, house, land cd’s alimony, child support, or stocks & bonds and cash value

    1. YES
    2. NO
23. 8. Copy of birth certificate

    1. YES
    2. NO
25. 9. Copy of marriage certificate or divorce decree

    1. YES
    2. NO
27. 10. Copy of guardianship papers

    1. YES
    2. NO
29. 11. Copy of Power of Attorney papers

    1. YES
    2. NO
31. The admission team will review the above information and will contact the applicant in a timely manner.
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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

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