The Manor At Woodside
The Manor At Woodside
168 Academy St.
Poughkeepsie, NY 12601
(845) 473-1943
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Providing A Distinctively Different Senior Living Residence

THE MANOR AT WOODSIDE

Personal Information
Name (F/M/L)
Telephone
Current Address
City County
State Zip
Previous Address
Social Security Number  
Birth Month Birth Date Birth Year
Present Marital Status Single Married Widowed Divorced
Applicant's Occupational History
Family and Social History
List below each living or nearest relative and indicate with an asterisk (*) whom to notify in case of an emergency.
A
  
Name Relationship
Address
Telephone
(home)		 Work
B
  
Name Relationship
Address
Telephone
(home)		 Work
C
  
Name Relationship
Address
Telephone
(home)		 Work
Responsible Party For Billing Purposes
Name Relationship
Address
Telephone
(home)		 Telephone
(Work)
Financial Information Income
Please complete all blanks. If there is no answer, mark 0 (zero).
Social Security Amount/Month $
Veteran Pension Amount/Month $
Annuity / Pension Amount/Month $
Public Assistance Grant Amount/Month $
Railroad Retirement Amount/Month $
Interest / Dividend Amount/Month $
Rental Amount/Month $
Other Sources
(Please Describe)
Total Monthly Income $
Financial Information Assets
(If married, please indicate joint assets)
1
  
Checking Accounts
Bank		 Current Balance $
Saving Accounts Current Accounts $
2
  
Checking Accounts
Bank		 Current Balance $
Saving Accounts Current Accounts $
Stocks, Bonds, C.D.s, Mutual Funds, Money Market Total Value $
Real Estate Location (s) Value $ Encumbrance (Mortgage) $
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Date  
Comments
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