Mary, Queen and Mother - Cardinal Ritter Senior Services

IF APPLYING FOR PRIVATE PAY CARE,The following information must also be completed prior to admission. The information isrequested in order to identify the applicant’s financial sources <strong>and</strong> to plan long-term financialobligations. All information given is strictly confidential.ASSETS:Checking AccountSaving AccountCertificates of DepositIndividual Retirement AccountsInvestmentsFunds in TrustHome (approximate value)Other Real Estate (approximate value)Other Assets(A) TOTAL ASSETS$____________$____________$____________$____________$____________$____________$____________$____________$____________$____________LIABILITIES:Home Mortgage (remaining balance) $____________Installment payments (remaining balance)$____________Other Liabilities$____________(B) TOTAL LIABILITIES$____________MONTHLY INCOME:(A)-(B)=NEW ASSET BALANCE $____________Social Security Veteran’s BenefitsPrivate PensionInterest/Dividend IncomeAnnuity IncomeTrust IncomeFrom Other PartiesOther (specify)___________________TOTAL MONTHLY INCOME$____________$____________$____________$____________$____________$____________$____________$____________$____________PLEASE TURN TO THE BACK COVER FOR THE NECESSARY SIGNATURE.3<strong>Mary</strong>, <strong>Queen</strong> <strong>and</strong> <strong>Mother</strong> Center · 7601 Watson Road · St. Louis, Missouri 63119 · Phone: 314-961-8000 ·