Western Assemblies Home

WESTERN ASSEMBLIES HOME 350 BERKELEY AVENUE CLAREMONT, CA 91711 909-626-3711 FAX 909-626-4493 License # 191502342

APPLICATION FOR RESIDENCY

APPLICANT NAME: ______

DATE: ______

1 WESTERN ASSEMBLIES HOME CLAREMONT, CALIFORNIA

APPLICATION FOR RESIDENCE (Please complete all questions)

POLICY STATEMENT

Residency at the Western Assemblies Home is limited to persons who fellowship with those Christians known as Plymouth Brethren, and who are in attendance and fellowship in a local assembly of Christians gathered to the Name of the Lord Jesus Christ. Once accepted as a resident it is required you keep in fellowship with a local assembly Acceptance is also, contingent upon a medical report provided by your personal physician, and approval by our Board of Directors. This form must be completed in its entirety.

Name of Applicant______

Address______City______State____Zip____

Telephone ( ) ______

Email Address ______

Marital Status: ( ) Married ( ) Single ( ) Widow/Widower ( ) Separated

Date of Birth______If Married spouse name______

Social Security#______Spouses Social Security #______

Please supply the following information

1. Are your activities limited by any adverse physical condition: Yes_____ No _____? If yes, please explain ______

2. Are you now, or have you been, under Doctor’s care for other than a routine illness during the past five years? Yes_____ No_____ If yes, please explain______

3. Are you on a special or restricted diet? Yes_____ No_____ If yes, please explain______

APPLICATION FOR RESIDENCY (Please complete all questions)

4. Financial Information (Confidential)

(a) SOURCES & AMOUNT OF INCOME: Social Security $______Supplementary Assistance $______Other $______

Please complete attached Financial listing your assets and liabilities. (This is necessary to Enable us to plan for your care)

(b) Do you have MEDICARE Insurance? Yes_____ No_____ Other______Note: Every Resident must be willing to apply for all Governmental assistance if necessary.

(c) Please have the attached Relatives Statement of Responsibility completed. If no relatives, please initial______.

(d) I understand there is a one-time, non-refundable Admission Fee of $1750 individual or $3000 couple. ______Initial

As the cost of your maintenance at Western Assemblies Home is not fully covered by the monthly fee you pay, have you considered including Western Assemblies Home in your trust or will?

The Administrator is available to talk with you regarding this matter, and will be happy to counsel you. All donations to Western Assemblies Home are tax deductible. Thank you for your consideration.

FINANCIAL

5. The policy of the Western Assemblies Home is that no Believer will be turned away due to their financial needs. The Board of Directors has established a Benevolent Fund to provide for the difference in the rent fees and what a resident can pay. The fund is generously provided by local assemblies. In order to see if you qualify for this fund we request you answer the following questions.

List the top three sources of your monthly income:

1.______

2.______

3.______

What are your current monthly expenses? ______

List the top three monthly expenses.

1.______

2.______

3.______

List amounts currently in:

Checking ______

Savings ______

Do you have Health Care Power of Attorney? ______

Do you have a Will? ______

Do you have a Living Trust? ______

RECOMMONDATION OF ASSEMBLY

APPLICANT: ______

ASSEMBLY: ______

COMMENDATION:

______

ELDERS:

______

RELATIVE’S STATEMENT OF RESPONSIBILITY

We/I, the relative(s) of ______, do hereby declare that we/I will, as necessary and without hesitation, assist in the financial responsibilities of ______in regards to his/her maintenance at Western Assemblies Home, based on the Home’s minimum requirements. We/I are/am willing to negotiate this responsibility with Western Assemblies Home as the need is brought to our/my attention.

Signature (s) Date Relationship

______

Address______

______

Address______

______

Address______

PERSONAL HISTORY STATEMENT

Please make a brief statement relative to your historical background, including your Assembly affiliations.

______

SIGNED: ______

YEARLY RATE DISCLOSURE

The Western Assemblies Home may raise or lower the monthly fee not more than 10% in one calendar year.

Each such increase shall be solely for the purpose of operating the Home on a sound financial basis for the benefit of all its residents and shall not be for the purpose of profit to the Home.

The last 3 years rate increase has been as follows:

2007 3.0% 2008 5.0% 2009 3.5% 2010 10.0%

Rates start at $1500.00 depending on room size and the resident’s individual needs. ______(Residents or Responsible Person’s Initials)