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Personal Information
First Name
Last Name
Date of Birth
SS#
Marital Status
Address1
City
State
Zip
Religious Information
Church Affiliation
Name of Church
Do you have a funeral Trust?
Funeral Home
Residency Information
Years of residency (as an adult) in Ozaukee County:
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:
Name
Relationship to Applicant
Address
# of years in Ozaukee County
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Social History
Your profession or occupation before retiring
What are your hobbies
Were you in the military service?
1. Yes
1. No
If yes, what branch?
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Medical Information
Primary Physician
Specialty
Phone
Other Physician
Specialty
Phone
Hospital Preference
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Confidential Financial Information
This confidential financial information will be used in determining your ability to meet financial obligations. It is used solely by Lasata Crossings.
Real Estate
Estimated Market Value
Amount of Mortgage
Equity Value
Approximate Amount
If multiple amounts exist, please add to proximate amount and enter in space above.
Savings or Money Market Accounts
If multiple accounts exist, please add to equal Approximate amount and enter on line above.
Certificates of Deposit
Total Approximate Value
Stocks & Bonds
Total Approximate Value
Total Value of above Assets
Monthly Income
Social Security
Pension
Annuities
Rental or Real Estate
Interest
Dividends
Trust Income
Other Income
Total Monthly Income
Sold or Given Away Assets?
1. Yes
1. No
Have you sold or given away any assets or property in the past sixty (60) months? If so, please provide details including what, how much, to whom and when. If so fill out the section below.
Please describe any assets or property you sold in the last sixty (60) months.
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Emergency Contact
First Name
Last Name
Primary Phone
Alternative Phone
Address
City
State
Zip
Email Address
First Name
Last Name
Primary Phone
Alternative Phone
Address
City
State
Zip
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To Whom Should the Billing Statement be sent?
First Name
Last Name
Primary Phone
Alternative Phone
Address
City
State
Zip
Guarantee of Payment
I agree to be responsible and pay for all sums due and owing Lasata Crossings upon receipt of bill. In the event that I am entitled to Public Funding benefits, such benefits are assigned to Lasata Crossings for application on my bill under terms as are required by the programs. I am aware that charges for room and board, services, and supplies are made monthly and are for services received in the prior month. I agree to be responsible and pay for all sums not covered by these assignments.
If accepted for admissions to Lasata Crossings, I agree not to take any inappropriate disposition (divestment) of assets, which would impair my ability to pay for my care.
I hereby certify that the information given is true and is representative of my financial conditions. I hereby give Lasata Crossings permission to verify the information given herein. 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 Crossings, if admitted.
I make this application for admission to Lasata Crossings 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.
Digital Signature
Date
Date
When are you looking to move in (approximate month)?
How were you referred to us?

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1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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Application for Residency at Lasata Crossings

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