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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:
This confidential financial information will be used in determining your ability to meet financial obligations. It is used solely by Lasata Crossings.
If multiple amounts exist, please add to proximate amount and enter in space above.
If multiple accounts exist, please add to equal Approximate amount and enter on line above.
Total Approximate Value
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.
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.
This field is not part of the form submission.
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