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Apply to Join Good Shepherd Communities

Level of Care
Good Shepherd Communities offers the following healthcare accommodations. Please indicate the level for which you are applying:
Good Shepherd Village at Endwell
- Skilled Nursing Facility (SNF)
- Assisted Living Residence (ALR)*
- Special Needs Assisted Living Residence (SNALR)*
*Enhanced services available at both ALR and SNALR
Good Shepherd Fairview Home at Binghamton
- Skilled Nursing Facility (SNF)
- Assisted Living Program (ALP)
- Assisted Living Residence (ALR)*
- Apartments for Independent Living (APT)
*Enhanced services available at ALR
Chase Memorial
- Skilled Nursing Facility (SNF)

Applicant Information
Name in Full:
- Ms.
- Miss
- Mrs.
- Mr.
Name*
First Last
Applicant's Email*
Telephone #:*
County of Residence:*
Home Address:*
(correspondence will be sent to the applicant unless otherwise stated below)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is the Home Address different from the Applicant's Mailing Address?*
- Yes
- No
Applicant's Mailing Address:*
(if different than above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Person to be contacted when an opening becomes available:*
Telephone #:*
Email Address:*

Financial Information
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 provide copies of all current bank and brokerage firm statements and list all amounts on this application. Please have available upon request a copy of HCP, POR, DMR and insurance card.*
Drop files here or

Max. file size: 300 MB.
INCOME:
1. Social Security Income:*
Presently receiving yearly (after deductions for Medicare):

2. Annuities or Endowment Income:

Company:	Frequency of payment:	No. of years:	Amount per year:	Actions

There are no Entries.

3. Pension or Retirement Plans:*
(please indicate if applicant’s or spouse’s pension)
a. Is there a cost of living inflator and if so, how does it work?*
b. If spouse’s, what happens on death of a spouse?*

Pension or Retirement Plans

Plan of Payment (For Life or No. of Years, etc.)	Actions

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4. Trust Funds:*
(You must provide a copy of the complete document, including any attachments, addendums and/or amendments)
Drop files here or

Max. file size: 300 MB.
Plan of Payment
Monthly: Actions
There are no Entries.
Maximum number of entries reached.
Who Administers:*
Do you have access to the principal?*
- Yes
- No
If yes, list amount $:*

Monthly:	Actions

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5. Other Income

Source: Dividends & Interest – both taxable and non-taxable

Monthly:	Yearly:	Actions

There are no Entries.

5. Other Income

Source: Rental Income

Monthly:	Yearly:	Actions

There are no Entries.

5. Other Income

Source: Other (specify)

Home Phone:	Address:	Relationship:	Actions

There are no Entries.

Health Insurance
Health Insurance
I'm interested In Actions
There are no Entries.
Maximum number of entries reached.

I'm interested In	Actions

There are no Entries.

Liabilities
23. Installment Debts
24. Insurance Premiums
24a. Long-Term Care
24b. Other
25. Loan/Pledges against Stocks or Bonds
26. Real Estate Loans
27. Personal Notes, Loans, Guarantees
28 Other Liabilities
28a. Other Liabilities cont.
28b. Other Liabilities cont.
29. TOTAL LIABILITIES
(calculated)
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.
Have you executed a trust for your own or someone else’s benefit?*
- Yes
- No
If yes, please provide a copy.*
Max. file size: 300 MB.
Have you gifted or transferred any assets to other persons or entities in the past 6 years?*
- Yes
- No
If yes, please provide and explanation, dates, and amount.*
Have you executed a promissory note or loan to other persons or entities in the past 6 years?*
- Yes
- No
If yes, please provide and explanation, dates, and amount.*
Were you required to file a Federal or State Income Tax Return last year?*
- Yes
- No
If yes, please provide a copy.*
Max. file size: 300 MB.

PLEASE NOTE: 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.
Declaration of Applicant
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.
Signature of Applicant*
Date*
Month
Day
Year
Signature of Designee*
Date*
Month
Day
Year