Please check all that apply.
Copies REQUIRED upon admission.
Skilled Nursing Residents Only:
Thrifty White Drug will be utilized when you are covered by Medicare A
Except for personal effects, list all the assets owned by YOU and YOUR SPOUSE, with the value as of the date of application.
Description of Assets
Approx. Value of Assets
Savings - Passbook
Certificates of Deposit
Stocks, Bonds, IRAs, Annuities, etc.
Life Insurance - Cash Surrender Value
Trust - Year Created
List all debts owed by you and your spouse, with outstanding balance as of the date of application. This includes mortgages, credit cards, vehicles or personal loansInclude any garnishments from Social Security or other income (tax lien, student loans, child support, etc.)
Description of Debt
Approx. Amount of Debt
List all sources of income for YOU and YOUR SPOUSE, including but not limited to rental payments, CRP income, long term care insurance benefits, Social Security Benefits, Veteran Benefits, alimony, and employment income.
Description of Income
Frequency of Income
Amount of Income
SIGNATURE LINE The undersigned represent that all of the above statements are true and complete. The application complies with section 50-24.1-22 of the North Dakota Century Code, and I hereby authorize the long term care facility to contact any and all of the above identified financial institutions to obtain information regarding my assets and income, and I hereby release and authorize the financial institutions to release any information to the long term care facility. I further authorize the long term care facility to release to its attorneys any information regarding my application for admission.