Residency – Lindemann Healthcare

Care Home - Applying to, please select from menu*

Name of Proposed Resident*

First Last

Preferred Name (if applicable)

Present Home Address*

Street Address Address Line 2 City Region Post Code Country

Do you have an appointed Power of Attorney (POA) or guardian?*

Please give Name of POA

Next of Kin*

Relationship*

Home Address of POA or NOK*

Street Address Address Line 2 City Region Post Code Country

Home Tel

Work Tel

Mobile Tel*

Email contact:*

Account to be sent to

Same as present address?

Street Address Address Line 2 City Region Post Code Country

Who is your local authority council?

Have you been assessed by social work for Free personal and Nursing Care allowance?*

Can the requirement of minimum 4 years funding guarantee be met?*

This equates to circa £215,000 in assets to cover a minimum 3 year term

Savings Held*

Do you have a property to sell?*

Approximate value of any property/equity held*

Retirement Pension

Other Pension

Interest from Savings

Signature*

Date*

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