Senior Residential Facility in Bedford, Ohio

APPLICATION Materials

Application for Admission – Part 2

Financial Disclosure

Thank you for considering residency at Light of Hearts Villa. To aid us in assessing whether you meet our financial criteria, we would like to review your financial resources. As a new resident, we require documentation showing the financial ability to get through one full year of private pay prior to accepting the Medicaid Assisted Living Waiver or other resources. Once determined, we can then establish a clear understanding of the financial responsibility you will be undertaking. We require this information of all residents; it is a part of our admissions process here at Light of Hearts Villa. Please enclose all requested documents. All information will be kept confidential. If you choose our facility, this form will become part of your admission agreement.

Please include copies of your most recent bank statements, investment statements,
and other pertinent financial documents with this disclosure. You will need to have the following documents available to complete this form:

  • Copy of Photo ID – front and back
  • Copy of Medicare Card – front and back
  • Copy of Insurance Card – front and back
  • Copy of Prescription Card – front and back
  • Copy of Covid Vaccine Card – front and back
  • Living Will – if you have one
  • POA Document – if you have one
  • POA for Health Care – must have
  • Copies of recent bank statements, investment statements, and other pertinent financial documents

"*" indicates required fields

General Information

Prospective Resident’s Name:
Is there a spouse?

Financial Information

1. Household Income

Please select YES or NO in every space provided below. Fill in monthly amounts as applicable.

DO YOU RECEIVE?

Income Source - Social Security
Income Source - VA Pension
Income Source - Retirement Pension
2. Household Assets

Please select YES or NO in every space provided below. List amount of asset where applicable.


Asset
Checking Account(s)
Savings Account(s)/Money Market
Cds
Stocks
Bonds
IRAs
Installment Notes
Property
Life Insurance Policy, Long-Term Care Insurance, Other Insurance
3. Liabilities

Please list any balance owed by the resident on the items below:


Type of Liability
House Loans
Credit Cards
Automobiles
Monthly Expenses
Notes
Other
Medical Expenses:
Doctor(s)
Prescriptions
Hospital
Other Medical Expenses
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              Application for Admission – Part 3

              Resident Profile
              MM slash DD slash YYYY
              Name*
              Preferred Name/Nickname
              MM slash DD slash YYYY
              CURRENT ADDRESS*
              Veteran
              Marital Status:
              List names of each child:
              Name
              Phone
              Email
               
              Recreational History:
              Interests:

              Please check all that apply

              Cooking
              Dancing
              Decorating
              Exercise
              Games/Cards
              Gardening/Plants
              Home Improvements
              History
              Movies
              Nature / Outdoors
              Painting
              Parties / Social
              Pets
              Puzzles
              Reading / Writing
              Shopping
              Sports
              Arts and Crafts
              Trips / Outings
              Socialization
              Watching TV
              Other:
              Spiritual Care:
              Do you Enjoy?
              YesNoAt Times
              Participates in group activities
              Participates in individual activities
              Initiates own activities
              Relates to others
              Friendly
              Withdrawn
              Tell us about your daily routine:
              Other Information:

              Giving

              ways to give
              why give
              naming opportunities
              memorial gifts

              NEWS & updates

              Sister Regina Kusnir Chapel of Light: A Legacy of Faith and Compassion

              Sister Regina Kusnir, SC, has lived a life of extraordinary charity and has been an integral part of Light of Hearts Villa. She helped coordinate the transition of Lumen Cordium High School into an assisted living facility in 1989. Since 2005, she has served as the director of pastoral and special ministries, where she helps address the spiritual life of residents.

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