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Step 1 of 6

16%
Applicant’s Name(Required)
Location(Required)
Home Address(Required)
Date of Birth(Required)
Veteran(Required)
Spouse of a Veteran(Required)
Fredonia Location - What are you interested in?(Required)
Williamsville Location - What are you interested in?(Required)
How did you hear about Fredonia Place?(Required)
Marital Status(Required)
Email Name Relationship Address Home Telephone Mobile TelephoneActions
      
There are no Entries.

Maximum number of entries reached.

Power of Attorney Name(Required)
(copy must be submitted upon move-in)
(copy must be submitted upon move-in)
(copy must be submitted upon move-in)
Health Care Proxy Name(Required)
(copy must be submitted upon move-in)
(copy must be submitted upon move-in)
(copy must be submitted upon move-in)
Prepaid Burial(Required)
Driving(Required)
Date of last appointment(Required)
Specialist Company Specialty Last AppointmentActions
    
There are no Entries.

Maximum number of entries reached.

Hospitalization in the last year(Required)
Does the applicant smoke?(Required)
Medicare Details(Required)
Medicaid(Required)
Private Insurance(Required)
Long Term Care Insurance(Required)
Other Insurance(Required)

Notice

Copies of insurance cards must be submitted upon move-in

Income

Applicant's Social Security per month
Spouse's Social Security per month
Total per month
Applicant's Annuity per month
Spouse's Annuity per month
Total per month
Applicant's Pension per month
Spouse's Pension per month
Total per month
Applicant's Interest/Dividends per month
Spouse's Interest/Dividends per month
Total per month
Applicant's Other Income per month
Spouse's Other Income per month
Total per month
Total per month

Assets

Total per month

Liabilities

Total per month
Will there be a Third Party Contributor
Who will guarantee the agreed rate(Required)
Address
3rd Party Contributor Income per month
3rd Party Spouse Income per month
Total per month
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.
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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