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Personal Information
Please fill in all fields in this section. If a field does not apply to you then, please enter “N/A” for not applicable.
First Name*
Last Name*
SSN*
First Name*
Last Name*
SSN*
Address1*
City*
State*
Zip*
Phone Number*
Are you:*
1. Single
1. Married
1. Widowed
1. Divorced
Date of Birth*
Spouse Date of Birth*
Years of Residency (as an adult) in Ozaukee County*
From*
To*
Out of County Applicants:
If you do not meet the residency requirement (currently living in Ozaukee County for at least 1 year), indicate the name and address of an immediate relative who does meet the residency requirement. Please fill in all fields in this section. Please note, if a field does not apply to you then, please enter “N/A” for not applicable.
First Name*
Last Name*
Relationship to Applicant
Address
City
State
Zip Code
Years in Ozaukee County
If you have children, please list:
Please fill in all fields in this section. If a field does not apply to you then, please enter “N/A” for not applicable.
Name*
Relationship*
Address/Phone*
Name*
Relationship*
Address/Phone*
Name*
Relationship*
Address/Phone*
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Financial Criteria
Please fill in all fields in this section. If a field does not apply to you then, please enter “N/A” for not applicable.
Do you presently own a home?*
1. Yes
1. No
If yes, what is the estimated value?*
Do you own other property?*
1. Yes
1. No
If yes, what is the estimated value?*
Financial Assets*
Liabilities*
Net Worth*
Annual Income*
List sources of income:*
Please be complete, including amounts for social security, pensions, interest on savings, face value of CD's, money markets, ect.
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Social History (Optional)
Please fill in all fields in this section. If a field does not apply to you then, please enter “N/A” for not applicable.
Your profession or occupation before retiring? *
What are your hobbies?*
Were you in the service?*
1. Yes
1. No
If yes, what branch?*
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Signature
Please fill in all fields in this section. If a field does not apply to you then, please enter “N/A” for not applicable.
Additional Informaiton
In order for your application to be considered, it 1) must be competed in full 2) be returned with the wait list fee of $500.00. Make checks payable to “Lasata Heights”
I make this application for admission to Lasata Heights of my own free will, with the knowledge that I may change my mind at any time and request a refund of the wait list fee. I certify that the above information is true and complete to the best of my knowledge. I understand that any false statements or willful misrepresentation shall be cause for rejection of my application and may be grounds for dismissal from Lasata Heights, if admitted.
By Checking this box I agree to terms in this Form*
1. I Agree
Current Date*
Current Date
Digital Signature *
Date*
Date
Digital Signature*
Date*
Date

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