Residential Living Waitlist Application

Date(Required)

Desired Move-In Time Frame

Desired Unit Style(Required)

Option 1

Option 2

Desired Entrance Plan(Required)

Entrance Fee

No Entrance Fee

Applicant 1

Name(Required)

First Middle Last

Date of Birth(Required)

Present Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Telephone Number(Required)

Email

Marital Status(Required)

Single

Married

Widowed

Divorced

Power of Attorney or Emergency Contact

Name

Relationship

Phone Number

Email

Power of Attorney

Yes

No

Is there a 2nd Applicant?(Required)

Yes

No

Applicant 2

Name(Required)

First Middle Last

Date of Birth(Required)

Telephone Number(Required)

Email

Marital Status(Required)

Single

Married

Widowed

Divorced

Power of Attorney

Yes

No

Power of Attorney or Emergency Contact

Name

Relationship

Phone Number

Email

Financial Statement

This Financial Statement is Part of the Application Process and Must Be Completed. Information Will Be Kept Confidential. If you have joint finances only fill out the Applicant 1 column. If you have separate finances, fill out Applicant 1 and Applicant 2 columns.

Any money given to families, or an organization within the last 5 years?(Required)

Yes

No

If YES, to whom and when was it transfered:

Amount

Applicant 1

Account Values(Required)

Checking Account

Savings Account

Stocks and Bonds

Annuities

CDs

Other

Real Estate

Enter numeric values only.

If you entered an amount in OTHER, please specify where this amount comes from. ie: 401k, money market, etc.,

Account Values(Required)

Total Assets

Total Liabilities (Debt)

Enter numeric values only.

Real Estate Details

If owning more than one property please provide address

Month Income(Required)

Social Security

Pension

Annuities

Dividends

Other

Enter numeric values only.

Applicant 2

Account Values

Checking Account

Savings Account

Stocks and Bonds

Annuities

CDs

Other

Real Estate

Enter numeric values only.

Account Values

Total Assets

Total Liabilities (Debt)

Enter numeric values only.

Real Estate Details

If owning more than one property please provide address

Month Income

Social Security

Pension

Annuities

Dividends

Other

Enter numeric values only.

Long Term Care Insurance

Applicant 1

Applicant 2

*If you have Long Term Care Insurance please submit a schedule of your benefits.

Health Insurance Name/Medicare Provider

Applicant 1

Applicant 2

Suplemental Insurance

Applicant 1

Applicant 2

Following receipt of this application and a $200 non-refundable application fee, Londonderry Village will evaluate the application and inform applicant(s) if they have been accepted for the Wait List.
Acceptance for the Wait List does not guarantee acceptance for admission. When a unit becomes available and is offered to applicant(s), applicant must meet the Conditions of Occupancy outlined in the resident agreements.
Acceptance for the Wait List requires that each applicant must pass the Megan’s Law background screening, which will be completed by Londonderry Village at the time the application is submitted for review.
It is customary for Londonderry Village to require an updated financial statement if the application has been on file for a year or more before admission into the community.
Applicant hereby applies to join the Wait List of Londonderry Village, and certifies that all of theinformation provided on this application is true and accurate to the best of their knowledge.
Londonderry Village does allow pets on campus in accordance with our pet policy, which is available upon request.

Applicant 1 Signature / POA Signature(Required)

Date(Required)

Applicant 2 Signature / POA Signature(Required)

Date(Required)