Application – Mezzaninep1v0t2019-01-25T15:02:41-06:00

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 ZIP Code
Racial categories*
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*
How soon are you contemplating a move?*
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?*
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

The Mezzanine at Golden West

Application for Residency

Applicant(s) Information

Annual Income Information

Living Situation

Pre-Assessment Checklist

Signature