KNOLLWOOD

6200 Oregon Avenue, N.W. Washington, D.C. 20015

Application Form

Applicant Name(s):  
Applying for:   (S)ingle or (C)ouple:
Move In Date Desired:  
Apartment Type Desired:  
Date of Application:   / /
Social Security #:  
Date of Birth:   / /
Military Card #: Expiration. Date:   / /
    Single Married Divorced Widowed
Number of Children:  
Number of Living Children:  
     
  Spouse Information
Name:  
Social Security #:  
Military ID Card #:  
Expiration Date:   / /
Date Of Birth:   / /
Date Of Marriage:   / /
Place of Marriage:  
     
  Current Address
Street Address:  
City:  
State:  
Zip:  
Home Phone:  
Work Phone:  
Current or Former Occupation:  
     
    If applicant is an officer, fill in this section
Branch of Service:  
Years of Service:  
Rank:  
Date of Commission:   / /
Source of Commission:  
Date Retired:   / /
Military Privileges:   Yes No
     
    If applicant is not an officer, fill in the sponsor information below
Name:  
Relationship:  
Address:  
City:  
State:  
Zip:  
Phone Number:  
Rank:  
Years of Service:  
Branch of Service:  
Source of Commission:  
Soc Sec #:   . .
Service #:  
Date of Commission:   / /
Sponsor Date:   / /
Retired:   / /
Date Deceased:   / /
     


    Medicare / Medicaid Information
Medicare# (including Letter):  
Medicare Part A:   Yes No
Medicare Part B:   Yes No
Medicare Start Date:   / /
Spouse's Medicare # (including letter):  
     
    Insurance Information
Health Insurance Co.:  
Long Term Care
Insurance Company		  
Husband or Wife:  
Policy Number:  
Type of Policy:  
     
    Will / Power of Attorney
General Power of Attorney Name:  
Phone:  
Will:   Yes No
Executor/Executrix Name:  
Executor Address:  
City:  
State:  
Zip:  
Executor Phone #:  
State where executed:  
Advance Directives   Yes No
Durable Power of Attorney for Medical:   Yes No
Living Will:   Yes No
     
    Primary Contact
Name:  
Address:  
City:  
State:  
Zip:  
Phone:  
Relationship:  
     
    Notes
I do  
I do not have sufficient financial resources to pay my admission fee and monthly service charge  
    Please attach a copy of retirement orders or DD Form 214
     
    My assets and sources of income are as follows
Description of Property  
Ownership Approx. Value Amount:  
Sole/Joint Property and Encumbrance:  
Interest:  
My annual income from all sources (i.e., retirement pension, compensation, Retired Serviceman’s Family Protection Plan, Survivor’s Benefit Plan, investment income, old age assistance or Social Security):  
Source Amount Per Month:  
I am covered by Medicare Hospitalization Insurance under Social Security.  
I am not covered by Medicare Hospitalization Insurance under Social Security.  
I am enrolled under the medical insurance part of Medicare  
I am not enrolled under the medical insurance part of Medicare  
     

I agree that when I become a resident of Knollwood, I will, if eligible, enroll in, or remain enrolled in, Medicare and the medical insurance part of Medicare; or provide my own private insurance coverage which, in the judgment of The Army Distaff Foundation, Inc., will provide substantially equivalent benefits.

I currently have the following health, hospitalization, long term care or surgical insurance:
Name of Company:  
Amount and type:  
    Please fax the application to 202-364-2856.
   
I hereby authorize any organization, person or governmental agency having knowledge of my affairs to disclose to The Army Distaff Foundation, Inc., its officers or representatives, any and all information concerning physical, business, property or financial condition. And, if my financial situation requires it, I authorize the Foundation to explore with my near relatives the assistance, if any, which they may be able to give me. I understand that information contained herein or acquired as a result hereof pertaining to my physical condition and my financial and business affairs will be treated as confidential by the Foundation.

Submitted herewith is my application deposit in the form of a check or money order, for $1,500.00, payable to The Army Distaff Foundation, Inc. If my application to Knollwood is accepted, this deposit will be applied toward my Admission Fee. If my application is not accepted, my deposit will be returned. The application deposit will not be returned after a contract has been signed.

Upon acceptance of this application, and my signing a contract, I understand that an initial contract payment of $3,500 must be paid. The $3,500 amount paid will be applied towards the total admission fee, and will only be refunded in the event of withdrawal, or death. Once the $3,500 and a signed contract are received by the Foundation, I will then be placed on the future waiting list. This establishes my precedence for the type of apartment I have selected.

I understand that at the time of residency in Knollwood, I must fully pay the remainder of the total admission fee for the apartment type that I have selected, and that there will be an additional monthly service charge.

Signature of Applicant(s) Date

Signature of Witness

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