Independent Living Application Step 1 of 8 - Resident Information 0% Resident InformationResident Full Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last Person who be living at Westhaven Community.Resident Phone Number(Required)Resident Email(Required) Resident Current Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security Number(Required)Date of Birth(Required) MM slash DD slash YYYY Place of Birth(Required)Marital Status:MarriedSingleSeparatedDivorcedWidowName of Spouse First Last Date of death MM slash DD slash YYYY In Case of Emergency NotifyName First Last RelationshipAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Contact for Billing InformationName First Last RelationshipAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneHousing PreferenceOne Bath ApartmentTwo Bath Apartment AssestsCashAccounts ReceivableBank AccountsStocks/BondsHomeOther Real EstateCash Value of Life InsuranceOther AssetsTotal Assets LiabilitiesNotes PayableMortgage on HomeOther LiabilitiesTOTAL LIABILITIES MONTHLY INCOMEReal Estate RentalsInvestmentsSocial SecurityAnnuitiesPensionsTrust FundOther SourcesTOTAL MONTHLY INCOME Documents Upload Drop files here or Select files Max. file size: 128 MB, Max. files: 10. The following documents are needed in order to complete the application process. You can either submit them now online or bring them with you in person. Document List: ID Insurance Cards POA Paperwork Living Will The applicant further agrees and promises to maintain at a minimum in the future his/her present approximate financial position with regard to the ability to pay for Independent Living services. If the applicant significantly reduces his/her financial position so that he/she may no longer have the ability to pay, then the applicant understands and agrees that this change will justify Westhaven in then refusing or turning away the applicant from admission to Westhaven Independent Living.Date MM slash DD slash YYYY Signature
