Apartments, Garden Homes, & Cottages Application
Name of Applicant
Address
Phone Number
Social Security #
Date of Birth
/
Month
/
Day
Year
Date
Number of Vehicles
HOW DID YOU HEAR ABOUT US?
What are you most interested in?
1BR Apartment
2BR Apartment
Garden Home with Garage
Garden Home without Garage
Cottage
EMERGENCY/ADDITIONAL CONTACT
(family member or person to reach in case of emergency for the applicant)
Name
Address
Phone Number
Relationship
HOSPITAL & HEALTH INSURANCE
Health Insurance
MEDICARE Number
PRESENT LIVING ARRANGEMENTS (Please Describe)
HOBBIES & SPECIAL INTERESTS (Please Describe)
STEMENT OF HEALTH (Please describe any disabilities)
I hereby certify that the foregoing statements are true and correct. Consent is given to The Bibb County Health Care Authority to obtain verification of all information contained herein. I agree to notify the Bibb County Health Care Authority immediately should there be any change in the above information.
SOURCE OF INCOME
PER YEAR
Social Security
Disability
Pension
TOTAL ANNUAL INCOME
Applicant Signature
Date
/
Month
/
Day
Year
Date
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