Valley Memorial Homes
Application for Admission
Have you ever been convicted of or plead guilty to a sexual offense in a court of law?
How did you hear about us?
Word of Mouth
Please check all that apply.
Copies REQUIRED upon admission.
Do you currently use medications from the VA?
List in the order of whom you prefer we contact first
Secondary Contact - optional
Tertiary Contact - optional
Copies of cards REQUIRED prior to admission
Medicare Supplemental Insurance
Information in this section will assist with financial planning.
Have you or your acting Financial Power of Attorney sold, traded, transferred, or gifted any cash or assets to you or from you, or to or from a trust account?
If YES, please explain the nature of the transaction and the date it occurred.
Have you or your spouse resided on a farm in the past 5 years?
Except for personal effects, list all the assets owned by YOU and YOUR SPOUSE, with the value as of the date of application.
Description of Assets
Approx. Value of Assets
List all debts owed by you and your spouse, with outstanding balance as of the date of application. This includes mortgages, credit cards, vehicles or personal loansInclude any garnishments from Social Security or other income (tax lien, student loans, child support, etc.)
Description of Debt
Approx. Amount of Debt
List all sources of income for YOU and YOUR SPOUSE, including but not limited to rental payments, CRP income, long term care insurance benefits, Social Security Benefits, Veteran Benefits, alimony, and employment income.
Description of Income
Frequency of Income
Amount of Income
The undersigned represent that all of the above statements are true and complete. The application
complies with section 50-24.1-22 of the North Dakota Century Code, and I hereby authorize the long term care facility to
contact any and all of the above identified financial institutions to obtain information regarding my assets and income,
and I hereby release and authorize the financial institutions to release any information to the long term care facility. I
further authorize the long term care facility to release to its attorneys any information regarding my application for