Senior Residential Facility in Bedford, Ohio

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: