168 Academy St. Poughkeepsie, NY 12601 (845) 473-1943 Email
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THE MANOR AT WOODSIDE

Personal Information
Name (F/M/L)
Telephone
Current Address
City		County
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Previous Address
Social Security Number
Birth Month	January February March April May June July August September October November December	Birth Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 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	Wife Husband Daughter Son Sister Brother Daughter In-law Son In-law Grand Daughter Grand Son Aunt Uncle Other
Address
Telephone (home)		Work
B
Name		Relationship	Wife Husband Daughter Son Sister Brother Daughter In-law Son In-law Grand Daughter Grand Son Aunt Uncle Other
Address
Telephone (home)		Work
C
Name		Relationship	Wife Husband Daughter Son Sister Brother Daughter In-law Son In-law Grand Daughter Grand Son Aunt Uncle Other
Address
Telephone (home)		Work
Responsible Party For Billing Purposes
Name		Relationship	Wife Husband Daughter Son Sister Brother Daughter In-law Son In-law Grand Daughter Grand Son Aunt Uncle Other
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) $
Is there any special date by which you desire to enter The Manor At Woodside Yes No
Date
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