Apartment, GH, & Cottage Application

Apartments, Garden Homes, & Cottages Application
Name of Applicant
Address
Phone Number
Social Security #
Date of Birth

MonthDayYear
Date
Number of Vehicles
HOW DID YOU HEAR ABOUT US?
What are you most interested in?

1BR Apartment2BR ApartmentGarden Home with GarageGarden Home without GarageCottage
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

Clear
Date

MonthDayYear
Date
Should be Empty:

EMERGENCY/ADDITIONAL CONTACT