Admissions Application

Financial Inquiry - Part B

Personal Information

Date of Application

Name of Applicant

First Middle Last

Date of Birth

Phone

Spouse

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Current Income – Monthly

**Do not leave any fields blank. If there is nothing to report type $0**

Social Security – Self

Social Security – Spouse

Pension – Self

Pension – Spouse

Annuity – Self

Annuity – Spouse

Interest/Investment Inc. – Self

Interest/Investment Inc. – Spouse

Other Income – Self

Other Income – Spouse

Specify Other Income

Total Income – Self

Total Income – Spouse

Total Income – Combined

Assets

**Do not leave any fields blank. If there is nothing to report type $0**

Have you disposed of any assets in the past 5 years?

Yes

If yes, please list below:

Type of Asset

Dollar Valye

Date Disposed

Recipient

Cash on hand

Cash held for you by others

Held by whom?

Bank Information

Name of Bank/Credit Union

Address of Financial Institution

Account Type

Amount

Stocks and/or Bonds

Name

Approximate Value

Real Estate Owned

Name

Address of Real Estate

Approximate Value

Are you or your spouse a beneficiary of a trust fund (real estate or other)?

Yes

Do you or your spouse have a Life Estate interest in any assets (real estate or other)?

Yes

Have you or your spouse ever placed assets (real estate or other) into a trust for the benefit of another?

Yes

If yes, please describe. Include date established and value:

Life Insurance Policies

Company

Policy Number

Face Amount

Cash Value

Beneficiary

Burial Fund/Prepaid Burial Expenses

Paid To:

Phone Number:

Date Established:

Irrevocable? (Yes/No)

Approximate Value/Cost

Debts and Obligations

**Do not leave any fields blank. If there is nothing to report type $0**

Mortgage/Real Estate Loans

Owed to

Monthly Payment

Amount Owed

Notes Payable

Owed to

Monthly Payment

Amount Owed

Credit Card Debt

Owed to

Monthly Payment

Amount Owed

According to my best knowledge and belief, the information disclosed in this admission application is complete, accurate, and true in all respects. I agree, if admitted, to abide by the admission agreement of Bethany Life.

Signature of Applicant, or Person Completing this Application

Comments

This field is for validation purposes and should be left unchanged.