Wait List Application

Applicant’s Legal Name

Second Applicant

Address

City/State/Zip
E-mail
Do You Rent or Own your Home ?

Telephone

Marital Status:* SingleMarriedWidowedDivorced

Long-Term Care Insurance ?

Label

Applicant

Second Applicant

Date of Birth

Active Smoker*

YesNo

Westminster Village is a smoke free community

Place of Birth

Life Insurance Co.

Supplementary Health Insurance Co.

Pre-Retirement Occupation

Do you currently drive?*YesNo

Do you own a vehicle?*YesNo

CHILDREN (or nearest relative):

Name:

Relation:

Address:
City:

State:

Zip:

Telephone:
E-mail Address:

Name:

Relation:

Address:
City:

State:

Zip:

Telephone:
E-mail Address:

I/We acknowledge that approval for the wait list is made in reliance on the financial information provided on the back of this application. I/We declare that all statements made are true according to my/our best knowledge and belief. I/We understand the application will be reviewed prior to being accepted to the wait list and prior to establishing residency

Applicant

Second Applicant

ASSETS:

1.Equity in Residence
2.Other Real Estate Equity

Financial Assets

Applicant

Second Applicant

A. Stocks

B. Bonds

C. Mutual Funds

D. IRA

E. Trusts

F. Checking/Savings/CDs

G. Life Insurance (Cash Surrender Value)

H. Other

Total Combined Financial Assests:
Total Entrance Fee Amount:
Assets After Entrance Fee Paid:

MONTHLY INCOME:

Applicant % to 2nd Applicant

Second Applicant % to Applicant

Upon Death

Pension

Annuity

Interest

Dividends

Other

Total Monthly

Total combined monthly income:
Minus monthly service fee:
Net monthly income:

Approved:

Lesley Morrison Midkiff,
Chief Marketing Officer,
Westminster Village, Inc.

To complete your registration process please make sure you have completed the WAIT LIST AGREEMENT and the WAIT LIST APPLICATION.

Applicant

Second Applicant

Westminster Village is a smoke free community

CHILDREN (or nearest relative):

ASSETS:

Financial Assets

Applicant

Second Applicant

MONTHLY INCOME:

Applicant % to 2nd Applicant

Second Applicant % to Applicant