Good Shepherd Communities offers the following healthcare accommodations. Please indicate the level for which you are applying:

In accordance with Good Shepherds Communities’ (GSC) Statement of Financial Responsibility, please complete the following personal financial information, which is required prior to admission and upon request after admission. The information is needed to estimate the number of residents who will need financial assistance and to determine if the applicant has a source of payment, this information will be held in confidence and will not be released to any person, agency, or party other than the GCS and the GCSs advisors without the permission of the applicant. List below all sources of individual income and/or individual assets, restricted or unrestricted. For joint ownership, please indicate the proportional value.

PLEASE NOTIFY GOOD SHEPHERD COMMUNITIES OF ANY SIGNIFICANT CHANGES TO THIS APPLICATION OR THE APPLICANT'S STATUS. AT THE TIME AN OPENING OCCURS YOU MAY BE ASKED TO UPDATE THIS INFORMATION.

In completing the application for admission, I/we understand that the filing of this application does not oblige the applicant to enter Good Shepherd Communities (GSC), nor does it guarantee admission to GSC, it merely places the applicant’s name on the waiting list. I/we understand that I/we will be asked to update this information at such a time that the applicant may be considered for admission. I/We, the undersigned, affirm that the answers to all the questions are complete and accurate to the best of my/ our knowledge. I/We understand that any conveyance of a resident’s assets without adequate consideration that renders the resident unable to pay GSC’s bills as they become due, or that disqualifies the resident for Medicaid or SSI status for any period of time will be considered fraudulent by GSC. I/We will not, during residency, transfer or reduce resources needed to carry out my/our commitments to GSC.