Application for Admission to NEW ENGLAND HOMES FOR THE DEAF, INC.

154 Water St., Danvers, MA 01923 VP: 978-767-8784 TTY: 978-774-0445 Voice: 978-774-0445 Fax: 978-774-0271

FINANCIAL DATA Name of the applicant: _______________________________________________________ Social Security #:______________________________Medicare ID:_____________________ Medicaid/Masshealth ID:_______________________LTC insurance:____________________ Other Medical Insurance:_______________________________________________________

Information on this page is necessary for admission determination. Section A. INCOME Yes/No $$/month Provide_______________ Social Security _______ ___________ Copy of the check SSI _______ ___________ Copy of the check Veterans Benefits _______ ___________ Copy of the check Pension/Annuity _______ ___________ Copy of the check & contract Other (indicate) _______ ___________ Copy of the check & contract Section B. ASSETS Yes/No $$/Market Value Provide_________ Residence – own _______ ______________ Last property tax bill Other real estate _______ ______________ Last property tax bill Bank accounts: Checking _______ ______________ Latest statement(s)* Savings _______ ______________ Latest statement(s)* Certificates of deposit _______ ______________ Latest statement(s)* Investments: Stocks/Bonds _______ ______________ Latest statement(s)* Life Insurance _______ ______________ Copy of policy Prepaid burial account _______ ______________ Copy of contract or latest statement

if bank account Other: Specify _______ ______________ Name (print): _________________________ Signature: ______________________________ *Provide latest statements with this form immediately. You also need to provide statements for the last 5 years for a full admission consideration. Please contact appropriate institutions without delay.