Admissions

Are you interested in our New York Campuses or Pennsylvania Campuses?*
- New York
- Pennsylvania
Which campus are you interested in?*
- Elizabeth Church Campus
- Hilltop Campus
Which campus are you interested in?*
- Wesley Village Campus
- Tunkhannock Campus
Applicant's Name*
First Last
Residence: No. and Street*
P.O. Box No.
City*
State*
Zip Code*
Telephone No.*
Email*
Social Security No.
Birth Date*
MM slash DD slash YYYY
Sex*
Marital Status*
Are you a United States Citizen?*
- Yes
- No
Are you a Veteran?*
- Yes
- No

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Physician's Name*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Please identify any physical or mental limitations or impairments of the Applicant(s):*
Please check level of care/type of accomodation*
- Independent Living
- Residential Living
- Adult Care
- Assisted Living
- Skilled Nursing
- Short Stay Rehabilitative Services
Please check level of care/type of accomodation*
- Independent Living
- Residential Living
- Personal Care
- Skilled Nursing
Has the Applicant ever been a resident in another senior housing or nursing facility?*
- Yes
- No
How did you hear about us?*
Responsible Party*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Has any person been appointed as Power of Attorney or appointed as Guardian by a court?*
- Yes
- No
Name of person holding Power of Attorney
Guardian
Relationship
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Please provide a copy of Power of Attorney or Oder of Guardianship.
Max. file size: 2 GB.
Person to notify in an emergency*
Phone*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Person to notify to set up an interview*
Phone*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Is there a Health Care Proxy or Living Will?*
- Yes
- No
If yes, please provide a copy.
Max. file size: 2 GB.
Name of Agent
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

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Insurance
Medicare #*
Medicare Part*
- Part A
- Part B
- Part D
Medicare Supplemental Insurance*
Plan*
Long-Term Care Insurance*
Policy #*
Other Insurance*
Policy #*
Prescription Care*
Policy #*
Have you executed a trust?*
- Yes
- No
If you have executed a trust, please attach a copy to this application. This application will not be considered complete until a copy of any and all trust agreements executed by the applicant have been provided.
Max. file size: 2 GB.
On admission, you will be asked to provide copies of all your insurance cards including: Medicare, Medicaid, SSI, Blue Cross, Blue Shield, Prescription Plan and/or other health insurance cards where applicable

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DECLARATION OF APPLICANT
In completing this application for admission I affirm that, to the best of my knowledge, the answers to the above questions are complete and accurate. I understand that the filing of this application does not obligate me to enter, nor does it guarantee admission to the applicable retirement community. It merely places my name on the waiting list.
Signature*
Date*
MM slash DD slash YYYY
State and Federal laws prohibit discrimination based on race, color, creed, sex, age, national origin, sponsor, handicap or source of payment.
Please contact Residential Services Center at (570) 655-2891, ext. 297 for additional information on Wesley Village Campus. Please call (570) 836-2983 for additional information on the Tunkhannock Campus.
For additional information regarding the Hilltop Campus and Elizabeth Church Campus, please contact Residential Services Center, located at 286 Deyo Hill Rd., Johnson City, NY 13790, (607) 785-4100.

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FOR OFFICE USE ONLY
Faculty*
Applicant*
The Methodist Homes for the Aging Of the Wyoming Conference, its Affiliates and Managed Facilities
Applicant’s Financial Information Form
The following information is required by The Methodist Homes for the Aging of the Wyoming Conference, its Affiliates and Managed Facilities (the “Homes”). This information is used to determine whether the Homes is likely to be asked to contribute toward the future support of a resident and to determine whether the applicant has a source of payment. It will be held in confidence and not released to any persons, agency or party other than the Homes and the Homes’ advisors unless so directed by the applicant or unless the resident defaults on any obligation to the Homes or release of such information is required or permitted by law. Please complete the information requested below
ASSETS
Cash Assets
Checking Account(s)
Name and Address of Bank or Financial Institution
How Titled/Names
Balance
Saving Account(s)
Name and Address of Bank or Financial Institution
How Titled/Names
Balance
Certificates of Deposit
Name and Address of Bank or Financial Institution
How Titled/Names
Balance
Other
Name and Address of Bank or Financial Institution
How Titled/Names
Balance

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MARKETABLE SECURITIES
Stocks
Name and Address of Financial Institution
How Titled/Names
Market Value
Bonds
Name and Address of Financial Institution
How Titled/Names
Market Value
Mutual Funds
Name and Address of Financial Institution
How Titled/Names
Market Value
Other
Name and Address of Financial Institution
How Titled/Names
Market Value

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ANNUITIES
Name of Company
Owner
Beneficiary
Approximate Value
Name of Company
Owner
Beneficiary
Approximate Value
Name of Company
Owner
Beneficiary
Approximate Value
Name of Company
Owner
Beneficiary
Approximate Value

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REAL ESTATE ASSETS
Residential Home
Location
How Titles/Names
Approximate Value
Other Real Property
(e.g., summer home, commercial property, vacant land)
Location
How Titles/Names
Approximate Value

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IRA’S/RETIREMENT ACCOUNTS
Name of Company
Titled
Beneficiary
Approximate Value
Name of Company
Titled
Beneficiary
Approximate Value
Name of Company
Titled
Beneficiary
Approximate Value
Name of Company
Titled
Beneficiary
Approximate Value

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LIFE INSURANCE
Paid Up Policies
Company
Owner
Named Beneficiary
Cash Surrender Value
Company
Owner
Named Beneficiary
Cash Surrender Value
Life Policies Requiring Payment of Premiums
Company
Owner
Named Beneficiary
Cash Surrender Value

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LIABILITIES
Name of Creditor
Address of Creditor
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Property Securing Debt
Monthly Payment
Amount of Debt/Amount of Mortgage
Name of Creditor
Address of Creditor
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Property Securing Debt
Monthly Payment
Amount of Debt/Amount of Mortgage
Name of Creditor
Address of Creditor
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Property Securing Debt
Monthly Payment
Amount of Debt/Amount of Mortgage

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INCOME
Please indicate below the amount of income you receive from each of the following sources and whether this income is received monthly, quarterly, semi-annually or annually or on a periodic basis.
Social Security
How Often Received i.e. Monthly/Annually
Amount
Supplemental Security
How Often Received i.e. Monthly/Annually
Amount
Interest Income
How Often Received i.e. Monthly/Annually
Amount
Dividend Income
How Often Received i.e. Monthly/Annually
Amount
Pension
How Often Received i.e. Monthly/Annually
Amount
Rental Income
How Often Received i.e. Monthly/Annually
Amount
Annuity
How Often Received i.e. Monthly/Annually
Amount
Disability Income
How Often Received i.e. Monthly/Annually
Amount
Support from Relatives
How Often Received i.e. Monthly/Annually
Amount
Public Assistance
How Often Received i.e. Monthly/Annually
Amount
Veterans Benefits
How Often Received i.e. Monthly/Annually
Amount
Trust Income
How Often Received i.e. Monthly/Annually
Amount
Other
How Often Received i.e. Monthly/Annually
Amount
The undersigned acknowledge(s) that the Homes is relying on their representations and promises set forth herein in considering the applicant for admission. We understand that if any information has been falsely represented, then that is sufficient cause for the Homes’ denial of this Application for Admission.

The financial information set forth herein is a true and correct statement of the applicant’s current financial position. The undersigned acknowledge(s) that the Homes considers this application as a continuing statement of the applicant’s financial condition and the undersigned agree(s) to furnish the Homes with an updated financial statement as follows:

a) At any time there is a change in the applicant’s financial condition; or
b) Once annually when requested by the Homes ; or
c) At any time the applicant is in need of a different level of care and/or desires to transfer to another facility owned or operated by the Homes or an affiliate of the Homes and the applicant is applying to such different level of care or facility; or
d) At any time requested by the Homes in writing.
The undersigned acknowledge(s) that the Homes is relying on their representations and promises set forth herein in considering the applicant for admission. We understand that if any information has been falsely represented, then that is sufficient cause for the Homes’ denial of this Application for Admission.

The financial information set forth herein is a true and correct statement of the applicant’s current financial position. The undersigned acknowledge(s) that the Homes considers this application as a continuing statement of the applicant’s financial condition and the undersigned agree(s) to furnish the Homes with an updated financial statement as follows:

a) At any time there is a change in the applicant’s financial condition; or
b) Once annually when requested by the Homes ; and
c) At any time the applicant is in need of a different level of care and/or desires to transfer to another facility owned or operated by the Homes or an affiliate of the Homes and the applicant is applying to such different level of care or facility; and
d) At any time requested by the Homes in writing.

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If you have transferred or donated assets to other persons or entities, including trusts, in the past 60 months, please indicate exact dates and amounts below so we may review, in accordance with the SSI or Medicaid eligibility requirements.
Have you executed a Trust?*
- Yes
- No
If you have executed a trust, please attach a copy to this application. This application will not be considered complete until copies of any and all trust agreements executed by the applicant have been provided.
Max. file size: 2 GB.
Explanation regarding transfer or donation of assets. Please state the exact dates, the amounts, and the names of the persons receiving the gift or transfer

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The undersigned further understand(s) that a gift by the applicant which disqualifies the applicant for Medicaid status for any period of time may constitute a “fraudulent conveyance” under the New York State Debtor and Creditor Law and that the Homes intends to pursue its legal rights against the applicant and any person to whom the applicant makes a gift which constitutes a fraudulent transfer.

The undersigned acknowledge(s) that the Homes may request additional information and/or disclosures prior to accepting the applicant for admission to any of its facilities, and the applicant’s application for residency and this financial information form are not considered complete until all of such additional financial information and/or disclosures have been provided to the Homes and verified by the Homes. The undersigned hereby gives the Homes permission to verify all such additional financial information and/or disclosures with appropriate third parties.

The undersigned also acknowledge(s) that if the undersigned request(s) that the Homes provide financial assistance to the undersigned, the Homes may require the undersigned to provide additional financial information and/or disclosures. Such additional information and disclosures will need to be verified by the Homes with appropriate third parties prior to the grant of any such financial assistance. In such event, the undersigned hereby gives the Homes permission to verify all such additional financial information and disclosures with appropriate third parties.
The above information is affirmed under penalty of perjury on this date*
MM slash DD slash YYYY
Applicant
First Last
Applicant
First Last
Financially Responsible Party for Applicant
First Last
A photocopy of this Application shall have the same effect as an original
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Insurance

DECLARATION OF APPLICANT

FOR OFFICE USE ONLY

Applicant’s Financial Information Form

ASSETS

Cash Assets

Checking Account(s)

Saving Account(s)

Certificates of Deposit

Other

MARKETABLE SECURITIES

Stocks

Bonds

Mutual Funds

Other

ANNUITIES

REAL ESTATE ASSETS

Residential Home

Other Real Property

IRA’S/RETIREMENT ACCOUNTS

LIFE INSURANCE

Paid Up Policies

Life Policies Requiring Payment of Premiums

LIABILITIES

INCOME

Social Security

Supplemental Security

Interest Income

Dividend Income

Pension

Rental Income

Annuity

Disability Income

Support from Relatives

Public Assistance

Veterans Benefits

Trust Income

Other