ApplicationMount Joy Country Homes

This form is required to start the application process to any of Messiah Lifeways at Mount Joy Country Homes (“Mount Joy Country Homes“) accommodations. For final approval, additional paperwork may be required. There is no application fee.

1. Complete the entire application and return it to Mount Joy Country Homes. Photocopies are acceptable. For additional copies, call 717.653.2356 or visit MessiahLifeways.org/MJCH. Once complete, please submit to:

Messiah Lifeways at Mount Joy Country Homes106 Bayberry Drive

Mount Joy, PA 17552

2. Approval is based on a financial screening and pursuant to a Megan’s Law background check. After the application is received and reviewed, the applicant will be notified of their status. The qualified applicant’s name will be placed on our applicant list. Applicants will be contacted based on their application date, desired move-in time and availability of desired accommodations.

3. Mount Joy Country Homes seeks to ensure the security and safety of its residents. It is the policy of Mount Joy Country Homes to preclude the admission of an applicant to any component of Mount Joy Country Homes if: a) the Pennsylvania Megan’s Law website reveals that such applicant has been convicted of one or more of the sexual offenses listed under 42 Pa.C.S.A. §9799.14, the list of sexual offenses can be accessed via the following link: http://www.pameganslaw.state.pa.us/Registration.aspx?dt=; or b) the applicant is out-of-state and the sex offender registry for the applicable jurisdiction in which the applicant resides reveals that such applicant has been convicted of a sexual offense similar in nature to those offenses listed under 42 Pa.C.S.A. §9799.14. (NOTE: A copy of the sexual offenses listed under 42 Pa.C.S.A. §9799.14 is also available upon request.)

The application is being submitted for:

❏  Desired floor plan: _________________________________________________________

❏  Desired move in date: _____________________________ Preferred Refund Level: 50% 65% 90%

EQUAL HOUSINGOPPORTUNITY

Applicant 2 Information:

Name ______________________________________________ Date of Birth ____________________ Age ________

Sex _____ Marital Status _________________ Do you have an Advance Directive (Living Will)? ❏ Yes ❏ No

Address ________________________________________ City _____________________ State _____ Zip ________ (if different from applicant 1)

Home # ( ) _______________________________________ Cell # ( ) __________________________________

Are you living alone? ❏ Yes ❏ No - If no, with whom are you living? _________________________________

Social Security # _____________________________________ Medicare # ___________________________________

Secondary medical insurance (Medicare supplement) or HMO name _____________________________________

Contract/Identification # ______________________________ Group # _____________________________________

Medical Assistance # ____________________ Prescription drug plan name _________________________________

Long-term care insurance coverage (company name) __________________________________________________

Daily Benefit ________________ Length of coverage or cap _____________________________________________

Physician’s name _____________________________________ Phone # ( ) ________________________________

Email _______________________________________________

Name ______________________________________________ Date of Birth ____________________ Age ________

Sex ___________ Marital Status ___________ Do you have an Advance Directive (Living Will)? ❏ Yes ❏ No

Address ________________________________________ City _____________________ State _____ Zip ________

Home # ( ) _______________________________________ Cell # ( ) __________________________________

Are you living alone? ❏ Yes ❏ No - If no, with whom are you living? _________________________________

Social Security # _____________________________________ Medicare # ___________________________________

Secondary medical insurance (Medicare supplement) or HMO name _____________________________________

Contract/Identification # ______________________________ Group # _____________________________________

Medical Assistance # ____________________ Prescription drug plan name _________________________________

Long-term care insurance coverage (company name) __________________________________________________

Daily Benefit ________________ Length of coverage or cap _____________________________________________

Physician’s name _____________________________________ Phone # ( ) ________________________________

Email _______________________________________________

Applicant 1 Information:

Continue on back...

Are you or your spouse a Military Veteran? ❏ Yes ❏ No - If yes, which branch? ____________________

Emergency Contacts: (please attach a separate sheet if you would like to list more than 2 contacts)

1. Name ___________________________________ Relation ____________Power-of-attorney? ❏ Yes ❏ No

Street address _____________________________ City __________________State ____Zip Code _______

Home # ( ) _________________ Work # ( ) _________________ Cell # ( ) _________________

Email______________________________________________

2. Name ___________________________________ Relation ____________Power-of-attorney? ❏ Yes ❏ No

Street address _____________________________ City __________________State ____Zip Code _______

Home # ( ) _________________ Work # ( ) _________________ Cell # ( ) _________________

Email______________________________________________

Financial Disclosure StatementThis entire section must be completed in order for an application to be processed. Applicant 1 Applicant 2 JointAssetsChecking / Savings $ _____________________ $ ________________________ $_________________________CDs $ _____________________ $ ________________________ $_________________________Investment Accounts $ _____________________ $ ________________________ $_________________________IRA $ _____________________ $ ________________________ $_________________________Annuities $ _____________________ $ ________________________ $_________________________Revocable Trust $ _____________________ $ ________________________ $_________________________Primary Residence $ _____________________ $ ________________________ $_________________________Other Real Estate $ _____________________ $ ________________________ $_________________________Other Assets (Specify)________________ $ _____________________ $ ________________________ $_________________________

TOTAL ASSETS $ _____________________ $ _____________________ $_________________________

Liabilities Mortgage Debt $ _____________________ $ ________________________ $_________________________Loans $ _____________________ $ ________________________ $_________________________Credit Card $ _____________________ $ _____________________ $ ____________________Other (Specify) ________________ $ _____________________ $ _____________________ $ ____________________

TOTAL LIABILITIES $ _____________________ $ _____________________ $ ____________________

Monthly IncomeSocial Security $ _____________________ $ _____________________ $ ____________________ (net income)Pension $ _____________________ $ _____________________ $ ____________________IRA/401 Retirement $ _____________________ $ _____________________ $ ____________________Annuity $ _____________________ $ _____________________ $ ____________________Trusts $ _____________________ $ _____________________ $ ____________________Interest/Dividends $ _____________________ $ _____________________ $ ____________________Other (Specify) $ _____________________ $ _____________________ $ ____________________

TOTAL MONTHLY INCOME $ _____________________ $ _____________________ $_________________________

Is Burial Prepaid? ❏ Yes ❏ No

If applicable, please indicate the total amount of any assets or real estate gifted or sold at less than fair market value in the last 5 years? $______________ If applicable, please indicate the total amount of any assets transferred to an Irrevocable Trust in the last 5 years? $______________________

I (we) understand that the Financial Disclosure Statement provided above has been submitted for the purpose of obtaining admission to Mount Joy Country Homes. I (we) certify that the provided information is a true and complete statement of my (our) assets, liabilities and income and authorize Mount Joy Country Homes to research any information for verification. I (we) acknowledge that any material misrepresentation or nondisclosure of assets and liabilities may affect my (our) applicant status or residency at Mount Joy Country Homes. I understand Mount Joy Country Homes may request proof of financial status.

Applicant 1 (Signature)__________________________________________ Date _______________________

Applicant 2 (Signature)__________________________________________ Date _______________________

Messiah Lifeways at Mount Joy Country Homes welcomes all regardless of race, color, age, sex, religion, disability, national origin or ancestry. Admission to Messiah Lifeways at Mount Joy Country Homes is limited to older adults age 55 and better. This is a smoke-free community.

For Office Use Only

Review Date ________________________ Reviewed By __________________________________________

❏ Approved ❏ Denied ❏ Pending Details: __________________________________________

Level of Living ____________________________ Approved Floor Plan(s) __________________________

Notes _____________________________________________________________________________________

Megan’s Law Conviction ❏ Yes ❏ No Date ___________________________ Initials __________

106 Bayberry Drive | Mount Joy, PA 17552

Phone 717.653.2356 | mjch@messiahlifeways.org | MountJoyCountryHomes.org