Valley View Retirement Community Terrace Application

Thank you for taking the time to learn more about our community. We know that making a decision like this is a meaningful step, and we want you to feel supported throughout the process. As part of exploring whether this could be the right fit for you, we encourage you to complete our application for admission. This allows us to better understand your interest, your timing, and your needs, as well as review the financial requirements for potential future admission. Please know we’re here to answer any questions along the way. We look forward to learning more about you and helping you through this important decision. —Geli Losch, Senior Director of Resident Services. Phone: 717-935-2105, ext 1850. Email: [email protected]

Valley View Retirement Community (VVRC) will comply with all applicable federal and state anti-discrimination requirements with respect to its admissions and provision of services.

Application Submitted For:(Required)
I am ready to move in as soon as possible (Select One)(Required)
APPLICANT(Required)
MM slash DD slash YYYY
STATUS(Required)
ADDRESS INFORMATION(Required)

HOW DID YOU HEAR ABOUT VALLEY VIEW RETIREMENT COMMUNITY?

Resident Representative 1(Required)
Address(Required)

Emergency Contact 1(Required)
Address(Required)

Emergency Contact 2(Required)
Address(Required)

MEDICAL/INSURANCE INFORMATION(Required)
Medicare Number(Required)
Medicare Number
Social Security Number
Supplemental Insurance Company
Medicare Advantage/PPO
Medicare Part D or Pharmacy Plan
Long Term Insurance
Long Term Insurance

Medical History

Do we have permission to access your medical records?(Required)
Have you ever received mental health services?
Mental Health
Have you been admitted to an inpatient nursing facility in the last 90 days?(Required)
NURSING HOME/CARE FACILITY
Have you been admitted to a hospital in the last 30 days?(Required)
HOSPITAL

Financial Disclosure Statement

Assets: Please fill out each entry. If an entry is not applicable, enter 0.

1. CHECKING(Required)
Applicant
Joint
Total
2. SAVINGS/MONEY MARKET(Required)
Applicant
Joint
Total
3. CDS(Required)
Applicant
Joint
Total
4. MUTUAL FUNDS(Required)
Applicant
Joint
Total
5. STOCKS & BONDS(Required)
Applicant
Joint
Total
6. RETIREMENT FUNDS(Required)
Applicant
Joint
Total
7. TRUST FUND*(Required)
Applicant
Joint
Total
*Indicate amount that is available for your care.
8. ANNUITIES CASH VALUE*(Required)
Applicant
Joint
Total
*Indicate cash value that you can withdraw from the annuity without penalty.
9. LIFE INSURANCE CASH VALUE*(Required)
Applicant
Joint
Total
*Indicate the cash surrender value of a life insurance policy.
10. BURIAL RESERVE(Required)
Applicant
Joint
Total
11. OTHER
Applicant
Joint
Total

12. REAL ESTATE
If you do not have a recent appraisal of your home, use Zillow.com or Trulia.com to estimate market value. Sale of house may be required to meet criteria.

ADDRESS(Required)
RESIDENCE MARKET VALUE $(Required)
$
13. Have you (or your spouse) transferred any assets including real estate, to someone other than your spouse for less than full market value within the past five years?(Required)
Have you (or your spouse) transferred any assets into a trust within the past five years?(Required)

14. Liabilities/Debt

MORTGAGE BALANCE(Required)
Applicant
Joint
Total
CREDIT CARD BALANCE(Required)
Applicant
Joint
Total
CAR LOAN BALANCE(Required)
Applicant
Joint
Total

15. Net Income

SOCIAL SECURITY(Required)
Applicant/Month
Joint/Month
Total/Month
PENSION*(Required)
Applicant/Month
Joint/Month
Total/Month
If you are married, indicate what portion of your pension will remain for your spouse in the event of your death.
RIGHT OF SURVIVORSHIP(Required)
PERCENTAGE %
OTHER INCOME
Applicant/Month
Joint/Month
Total/Month

16. Monthly Expenses
Indicate expenses that will be incurred while residing at VVRC, such as car loan, car insurance, phone, internet, health insurance and life insurance.

MONTHLY EXPENSES(Required)
Expense
Applicant
Joint
Total
MONTHLY EXPENSES
Expense
Applicant
Joint
Total
MONTHLY EXPENSES
Expense
Applicant
Joint
Total
MONTHLY EXPENSES
Expense
Applicant
Joint
Total

AGREEMENT
I understand that Valley View Retirement Community (VVRC) will keep my information in strict confidence and will only use the information for necessary purposes. I understand that VVRC may request proof of financial status and periodic updated financial information. All applications are reviewed when admission is pending and updates will be required at that time. Applicants must meet the financial criteria in place at the time a residence is available for occupancy. All of the assets listed in this application as owned or controlled by me are entitled or registered in my individual or joint names, or held for my benefit, and are available to pay for all levels of care at VVRC. I have full power and authority to convey or utilize such assets for my personal support and for payment for services supplied through VVRC. I affirm that I (or my/our agent(s) will not deplete or jeopardize such assets below the level of that reasonably required to provide for my care, or substantially change the nature or liquidity of my assets. I acknowledge that if I jeopardize my ability to pay for my care, then I may be ineligible for admission to any level of care at VVRC and may be ineligible for financial assistance from VVRC, and I may jeopardize my ability to live at VVRC. I understand that it is the policy of VVRC to screen all incoming applicants against the National Sex Offender Registry Website. I understand that VVRC will deny admission to anyone listed on federal and/or state sex offender registry websites. I understand and acknowledge that VVRC relies on the information and disclosures made in this application for the purpose of inducing VVRC to consider me for admission. I certify that the information and disclosures provided in this application are true, correct, and complete to the best of my knowledge and belief. Although the application is not otherwise binding, I understand and agree that any misrepresentation or significant omission or misstatement of fact, including financial information, may be considered grounds for refusal of residency or dismissal after admission.
APPLICANT
Clear Signature
MM slash DD slash YYYY