Congregate Housing Application

Congregate Housing Application
Name of Applicant
Address
Phone Number
Social Security #
Date of Birth

MonthDayYear
Date
Place of Birth
SPONSOR (Family member or person responsible for the applicant)
Name
Address
Phone Number
Relationship
Other Relatives (Please give details)
SOURCE OF INCOME
Social Security (per month)
Disability (per month)
Pension (per month)
Disability
Dept. of Income Maintenance (per month)
Interest & Dividends (per month)
Dept. of Income Maintenance
Annuities (per month)
Other Income
TOTAL ANNUAL INCOME
ASSETS (Net Worth)
Stocks
Bonds
Bank Accounts
Home (Market Value)
Other Property (Market Value)
Amount
Amount
Other
Outstanding Debt
HOSPITAL & HEALTH INSURANCE
Blue Cross & Blue Shield Numbers
Other Health Insurance
MEDICARE Number
PRESENT LIVING ARRANGEMENTS (Please Describe)
HOBBIES & SPECIAL INTEREST (Please Describe)
STATEMENT OF HEALTH
STATEMENT OF HEALTH (Please describe any disabilities. Obtain a written statement from your doctor and provide medical documentation relating to the seven items under FITNESS in the Tenant Qualification Policy and Applicaiton Procedure)
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.
Applicant Signature

Clear
Date

MonthDayYear
Date
Should be Empty: