new england homes for the deaf, inc.nehd.org/site/wp-content/uploads/2016/05/nehd... · application...
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![Page 1: NEW ENGLAND HOMES FOR THE DEAF, INC.nehd.org/site/wp-content/uploads/2016/05/NEHD... · Application for Admission to NEW ENGLAND HOMES FOR THE DEAF, INC. 154 Water St., Danvers, MA](https://reader033.vdocuments.site/reader033/viewer/2022060920/60ac5752854e65146771f7f1/html5/thumbnails/1.jpg)
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Application for Admission to NEW ENGLAND HOMES FOR THE DEAF, INC.
154 Water St., Danvers, MA 01923 VP: 978-767-8784 TTY: 978-774-0445 Voice: 978-774-0445 Fax: 978-774-0271
FINANCIAL DATA Name of the applicant: _______________________________________________________ Social Security #:______________________________Medicare ID:_____________________ Medicaid/Masshealth ID:_______________________LTC insurance:____________________ Other Medical Insurance:_______________________________________________________
Information on this page is necessary for admission determination. Section A. INCOME Yes/No $$/month Provide_______________ Social Security _______ ___________ Copy of the check SSI _______ ___________ Copy of the check Veterans Benefits _______ ___________ Copy of the check Pension/Annuity _______ ___________ Copy of the check & contract Other (indicate) _______ ___________ Copy of the check & contract Section B. ASSETS Yes/No $$/Market Value Provide_________ Residence – own _______ ______________ Last property tax bill Other real estate _______ ______________ Last property tax bill Bank accounts: Checking _______ ______________ Latest statement(s)* Savings _______ ______________ Latest statement(s)* Certificates of deposit _______ ______________ Latest statement(s)* Investments: Stocks/Bonds _______ ______________ Latest statement(s)* Life Insurance _______ ______________ Copy of policy Prepaid burial account _______ ______________ Copy of contract or latest statement
if bank account Other: Specify _______ ______________ Name (print): _________________________ Signature: ______________________________ *Provide latest statements with this form immediately. You also need to provide statements for the last 5 years for a full admission consideration. Please contact appropriate institutions without delay.
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