The information is Strictly Confidential
Assets: Total Assets....(Including Checking, Savings, Stocks, Bonds, Investments, Real Estate)
Liabilities: Total Liabilities....(Including Credit Cards, Mortgage and Loans)
Monthly Income: Total Monthly Income....(Including Social Security, Pension, Interest Income and Royalties)
I (we) make this application for residence of my (our) own free will and accord. I (we) declare the information provided to the foregoing questions to be true, complete and an accurate financial account to the best of my (our) knowledge as of the date written below. i (we) authorize and request that my (our) attending physician, surgeon or other person having direct, professional knowledge on my (our) physical or mental health (past or present) provide to the staff at the Catholic Care Center any and all information relative here. Any false or misleading information will void the application approval and/or resident agreement.