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Application – Mezzanine
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2019-01-25T15:02:41-06:00
The Mezzanine at Golden West
Application for Residency
Applicant(s) Information
Name
*
First
Middle
Last
Phone
*
Email
*
Date of birth
*
Date Format: MM slash DD slash YYYY
Address
*
Street Address
City
State
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Connecticut
Delaware
District of Columbia
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Armed Forces Americas
Armed Forces Europe
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State
ZIP Code
Racial categories
*
African American
American Indian or Alaska Native
Asian
Caucasian
Hawaiian or Pacific Islander
Hispanic or Latino
Non-Hispanic or Latino
Other
I prefer not to disclose ethnic or racial information
Other
*
Please Initial
*
Partnership status
*
Single
Married
Partnered
Divorced
Widowed
Second applicant's name
*
First
Middle
Last
Phone
*
Email
*
Date of birth
*
Date Format: MM slash DD slash YYYY
Alternate contact
*
Relationship
*
Phone
*
Email
*
Address
*
Annual Income Information
Wages, commissions, fees received
*
Pension, retirement, annuity
*
Social Security
*
Old age assistance
*
Rents or royalties received
*
Interest on savings accounts
*
Dividends received on stocks, bonds, mutual funds
*
Other income
*
Total annual income
$0.00
Method of Payment
*
Private Pay
Medicaid (Do you currently receive HCBS benefits?)
Living Situation
Do you currently
*
Own
Rent
Live with family
Live in a retirement community
How soon are you contemplating a move?
*
ASAP
3-6 months
6-12 months
1-2 years
Unknown
Do you drive?
*
Yes
No
Do you own a car?
*
Yes
No
Do you have a pet?
*
Yes
No
Type of pet
*
Do you currently receive housing assistance? (i.e. Section 8)
*
Yes
No
Do you currently live in subsidized housing?
*
Yes
No
Apartment request
Please list any special apartment requirements. Keep in mind that limited preferences can prolong the waiting time.
How did you hear about Golden West?
*
Google Search
Print Ad
Online Ad
Friend or Family Member
Driving By
Other
Pre-Assessment Checklist
At Golden West, we take great pride in our long-standing history, culture, and the services we provide to seniors. In order to continue to provide the best environment for our residents, we go above and beyond in making certain that our current and potential future residents’ safety is protected. We hope that you will appreciate that the requested information assists us in securing that all precautions have been taken.
Is the future resident 62 or older?
*
Yes
No
The monthly rate for your apartment is $4,352 or Medicaid H.C.B.S, which is a flat fee and includes all of the amenities and services we can provide. Will this work within your budget?
*
Yes
No
Golden West will need a copy of your most recent tax return to to verify income & assets to ensure our fee fits within your budget. Can you provide one, and additional verification if needed?
*
Yes
No
The Mezzanine at Golden West is an assisted living community. It is not a medical facility and we do not have doctors, physical therapists or any other medical personnel on staff. Do these services meet your needs?
*
Yes
No
Golden West is a smoke-free community and no smoking is allowed anywhere on the property. Are you a smoker?
*
Yes
No
Can you comply with the smoking ban?
*
Yes
No
Golden West conducts landlord reference checks. Have you ever been evicted or involuntarily removed from any housing or residential situation?
*
Yes
No
Have you or any family members ever been convicted of a crime involving any type of violence, theft or illegal use of drugs?
*
Yes
No
Golden West will conduct a background check prior to move-in. Do you agree to this?
*
Yes
No
Signature
I have read The Mezzanine at Golden West eligibility requirements and the criteria for occupancy and affirm that I do qualify as an eligible resident. I agree to notify Golden West should any of the above information change. I declare that the above listed information is correct and true to the best of my knowledge.
Please enter your name to confirm and sign the application
*
First
Middle
Last
Comments
This field is for validation purposes and should be left unchanged.
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