Application for Residency - fredoniaplace.com

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Employee Portal

Step 1 of 6

16%

Applicant’s Name(Required)

First Last

Location(Required)

Fredonia

Williamsville

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Telephone

Mobile Telephone

Email(Required)

Former Occupation/Educational Background(Required)

Date of Birth(Required)

Month

Day

Year

Age(Required)

Gender(Required)

Social Security Number(Required)

Veteran(Required)

Yes

No

Spouse of a Veteran(Required)

Yes

No

Fredonia Location - What are you interested in?(Required)

Assisted Living

Liberty

Putnam

Barker

Lafayette

Memory Care

Williamsville Location - What are you interested in?(Required)

Assisted Living

Ellicott

Garrison

Neumann

Williams

Memory Care

How did you hear about Fredonia Place?(Required)

Website

Radio

Newspaper

Social Media

Friend

Other

Friends Name?(Required)

Other - Please Specify(Required)

Marital Status(Required)

Single

Married

Widowed

Divorced

Separated

Other

Other - Please Specify(Required)

Name of Spouse (if any)

Emergency Contact(s)

Email	Name	Relationship	Address	Home Telephone	Mobile Telephone	Actions

There are no Entries.

Maximum number of entries reached.

Power of Attorney Name(Required)

First Last

(copy must be submitted upon move-in)

Power of Attorney Relationship(Required)

(copy must be submitted upon move-in)

Power of Attorney Phone Number(Required)

(copy must be submitted upon move-in)

Health Care Proxy Name(Required)

First Last

(copy must be submitted upon move-in)

Health Care Proxy Relationship(Required)

(copy must be submitted upon move-in)

Health Care Proxy Phone Number(Required)

(copy must be submitted upon move-in)

Funeral Home(Required)

Prepaid Burial(Required)

Yes

No

Driving(Required)

Yes

No

Make(Required)

Model(Required)

Year(Required)

License Plate(Required)

Religious Affiliation

Church Name

Primary Care Physician Name(Required)

Company(Required)

Date of last appointment(Required)

Month

Day

Year

Specialist(s)

Specialist	Company	Specialty	Last Appointment	Actions

There are no Entries.

Maximum number of entries reached.

Hospitalization in the last year(Required)

Yes

No

Why?(Required)

Does the applicant smoke?(Required)

Yes

No

Medicare #(Required)

Medicare Details(Required)

Part A

Part B

Part C

Part D

Medicaid(Required)

Yes

No

Number?(Required)

Private Insurance(Required)

Yes

No

Who?(Required)

ID Number(Required)

Long Term Care Insurance(Required)

Yes

No

Who?(Required)

Other Insurance(Required)

Yes

No

Type(Required)

Policy #(Required)

Notice

Copies of insurance cards must be submitted upon move-in

Reason for Residency(Required)

Income

Applicant Social Security(Required)

Applicant's Social Security per month

Spouse Social Security(Required)

Spouse's Social Security per month

Total(Required)

Total per month

Applicant Annuity(Required)

Applicant's Annuity per month

Spouse Annuity(Required)

Spouse's Annuity per month

Total(Required)

Total per month

Applicant Pension(Required)

Applicant's Pension per month

Spouse Pension(Required)

Spouse's Pension per month

Total(Required)

Total per month

Applicant Interest/Dividends(Required)

Applicant's Interest/Dividends per month

Spouse Interest/Dividends(Required)

Spouse's Interest/Dividends per month

Total(Required)

Total per month

Applicant Other Income

Applicant's Other Income per month

Spouse Other Income

Spouse's Other Income per month

Total

Total per month

Total(Required)

Total per month

Please explain your other income(s)(Required)

Assets

Applicant Checking Account(Required)

Spouse Checking Account(Required)

Total(Required)

Applicant Savings Account(Required)

Spouse Savings Account(Required)

Total(Required)

Applicant Certificate of Deposit(Required)

Spouse Certificate of Deposit(Required)

Total(Required)

Applicant Life Insurance(Required)

Spouse Life Insurance(Required)

Total(Required)

Applicant Real Estate(Required)

Spouse Real Estate(Required)

Total(Required)

Applicant Stocks & Bonds(Required)

Spouse Stocks & Bonds(Required)

Total(Required)

Applicant Mutual Funds(Required)

Spouse Mutual Funds(Required)

Total(Required)

Applicant Automobiles(Required)

Spouse Automobiles(Required)

Total(Required)

Applicant Other Assets(Required)

Spouse Other Assets(Required)

Total(Required)

Total(Required)

Total per month

Liabilities

Applicant Real Estate(Required)

Spouse Real Estate(Required)

Total(Required)

Applicant Automobiles(Required)

Spouse Automobiles(Required)

Total(Required)

Applicant Credit Cards(Required)

Spouse Credit Cards(Required)

Total(Required)

Applicant Other(Required)

Spouse Other(Required)

Total(Required)

Total(Required)

Total per month

Will there be a Third Party Contributor

Yes

No

Who will guarantee the agreed rate(Required)

First Last

Signature of Third Party Contributor(Required)

Address

Street Address Address Line 2 City State ZIP Code

Home Telephone(Required)

Mobile Telephone(Required)

3rd Party Contributor Income(Required)

3rd Party Contributor Income per month

3rd Party Spouse Income(Required)

3rd Party Spouse Income per month

Total(Required)

Total per month

3rd Party Contributor Assets(Required)

3rd Party Spouse Assets(Required)

Total(Required)

3rd Party Contributor Debts(Required)

3rd Party Spouse Debts(Required)

Total(Required)

Total(Required)

Total per month

Statement of Accuracy

I hereby certify that the supplied information is correct and compete to the best of my knowledge. I understand that any misrepresentation could result in the forfeiture of my status as a resident at Fredonia Place, that this application does not obligate Fredonia Place in any way and that the information given herein is strictly confidential.

Applicant’s/Representative Signature(Required)

Email

This field is for validation purposes and should be left unchanged.

Fredonia
50 Howard Street
Fredonia, NY 14063
(716) 679-2250

Williamsville
201 Reist Street
Williamsville, NY 14221
(716) 632-2155

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