///The Mezzanine Application – Golden West Senior Living
The Mezzanine Application – Golden West Senior Living 2017-04-03T17:01:19+00:00

The Mezzanine Application for Residency

* Indicates a required field.

Date: *

Applicant(s) Information:

First Applicant's Name: *    Date of Birth: *

Second Applicant's Name:    Date of Birth:

Address: *     

Telephone: *  

E-mail:         

Marital Status: * SingleMarriedPartneredDivorcedWidowed

Method of Payment: * Private PayMedicaid (Do you currently receive HCBS benefits?)

Do you currently: *   OwnRentLive in a retirement communityLive with family

How soon are you contemplating a move? *  ASAP3-6 months6-12 months1-2 yearsUnknown

Do you drive? *  YesNo      Do you own a car? *YesNo

Do you own a pet? *  YesNo     If so, what kind?

Do you currently receive housing assistance? (i.e. Section 8) *   YesNo

Do you currently live in subsidized housing? *   YesNo

How did you hear about Golden West?   

Annual Income Information:

Wages, Commissions, Fees Received: * $   
Pension, Retirement, Annuity: * $   
Social Security: * $   
Old Age Assistance: * $   
Rents or Royalties Received: * $   
Interest on Savings Accounts, Etc.: * $   
Dividends Received on Stocks, Bonds, Mutual Funds: * $   
Other Income: * $   
Total Annual Income: * $   

Contact Information:

Alternative Contact:      Relationship:

Address:                             Telephone:  

Apartment Request:

Please list any special apartment requirements below. Keep in mind that limited preferences can prolong the waiting time.

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