Common use of Resources Clause in Contracts

Resources. Where your name or your *Any property that you owned within the last 60 months spouse’s name may be listed *Passbooks, bank statements (opened and closed accounts for the past 60 months) *Stocks, Bonds, Annuities *Investments/Brokerage Funds *Certificates of Deposit (CDs), Credit Union accounts, IRAs *Trust Agreement and Principal *Include any accounts/resources which may have been closed, cashed in, or transferred within the past 60 months *Income Tax returns, including 1099s (5 years) *Financial summary of any private payments made to a nursing home. *Verification and Clarification of any withdrawals or deposits over $2000 (copy of cancelled checks) deposit receipts LIFE INSURANCE: *Assessed value of house/property either current OR transferred within last 5 years *Copy of policy and verification of cash value, name of owner and policy number HEALTH INSURANCE: *Medicare Card *Identification Card for Health Insurance *Premium Amount *Proof of Payment VETERAN STATUS: *Military Discharge papers for applicant or spouse OTHER DOCUMENTS: *Copy of Power of. Attorney *Signed Authorization to represent form *Guardianship Papers *Itemized Irrevocable Burial Trust or Pre-need Agreement-(PAID IN FULL) THE GRAND REHABILITATION AND NURSING AT SOUTH POINT LIST OF ADDENDA

Resources. Where your name or your *Any property that you owned within the last 60 months spouse’s name may be listed *Passbooks, bank statements (opened and closed accounts for the past 60 months) *Stocks, Bonds, Annuities *Investments/Brokerage Funds *Certificates of Deposit (CDs), Credit Union accounts, IRAs *Trust Agreement and Principal *Include any accounts/resources which may have been closed, cashed in, or transferred within the past 60 months *Income Tax returns, including 1099s (5 years) *Financial summary of any private payments made to a nursing home. *Verification and Clarification of any withdrawals or deposits over $2000 (copy of cancelled checks) deposit receipts LIFE INSURANCE: *Assessed value of house/property either current OR transferred within last 5 years *Copy of policy and verification of cash value, name of owner and policy number HEALTH INSURANCE: *Medicare Card *Identification Card for Health Insurance *Premium Amount *Proof of Payment VETERAN STATUS: *Military Discharge papers for applicant or spouse OTHER DOCUMENTS: *Copy of Power of. Attorney *Signed Authorization to represent form *Guardianship Papers *Itemized Irrevocable Burial Trust or Pre-need Agreement-(PAID IN FULL) THE GRAND REHABILITATION AND NURSING AT SOUTH POINT UTICA LIST OF ADDENDA

Resources. Where your name or your *Any property that you owned within the last 60 months spouse’s name may be listed *Passbooks, bank statements (opened and closed accounts for the past 60 months) *Stocks, Bonds, Annuities *Investments/Brokerage Funds *Certificates of Deposit (CDs), Credit Union accounts, IRAs *Trust Agreement and Principal *Include any accounts/resources which may have been closed, cashed in, or transferred within the past 60 months *Income Tax returns, including 1099s (5 years) *Financial summary of any private payments made to a nursing home. *Verification and Clarification of any withdrawals or deposits over $2000 (copy of cancelled checks) deposit receipts LIFE INSURANCE: *Assessed value of house/property either current OR transferred within last 5 years *Copy of policy and verification of cash value, name of owner and policy number HEALTH INSURANCE: *Medicare Card *Identification Card for Health Insurance *Premium Amount *Proof of Payment VETERAN STATUS: *Military Discharge papers for applicant or spouse OTHER DOCUMENTS: *Copy of Power of. Attorney *Signed Authorization to represent form *Guardianship Papers *Itemized Irrevocable Burial Trust or Pre-need Agreement-(PAID IN FULL) THE GRAND REHABILITATION AND NURSING AT SOUTH POINT GUILDERLAND LIST OF ADDENDA

Resources. Where your name or your *Any property that you owned within the last 60 months spouse’s name may be listed *Passbooks, bank statements (opened and closed accounts for the past 60 months) *Stocks, Bonds, Annuities *Investments/Brokerage Funds *Certificates of Deposit (CDs), Credit Union accounts, IRAs *Trust Agreement and Principal *Include any accounts/resources which may have been closed, cashed in, or transferred within the past 60 months *Income Tax returns, including 1099s (5 years) *Financial summary of any private payments made to a nursing home. *Verification and Clarification of any withdrawals or deposits over $2000 (copy of cancelled checks) deposit receipts LIFE INSURANCE: *Assessed value of house/property either current OR transferred within last 5 years *Copy of policy and verification of cash value, name of owner and policy number HEALTH INSURANCE: *Medicare Card *Identification Card for Health Insurance *Premium Amount *Proof of Payment VETERAN STATUS: *Military Discharge papers for applicant or spouse OTHER DOCUMENTS: *Copy of Power of. Attorney *Signed Authorization to represent form *Guardianship Papers *Itemized Irrevocable Burial Trust or Pre-need Agreement-(PAID IN FULL) THE GRAND REHABILITATION AND NURSING AT SOUTH POINT BATAVIA LIST OF ADDENDA

Resources. Where your name or your *Any property that you owned within the last 60 months spouse’s name may be listed *Passbooks, bank statements (opened and closed accounts for the past 60 months) *Stocks, Bonds, Annuities *Investments/Brokerage Funds *Certificates of Deposit (CDs), Credit Union accounts, IRAs *Trust Agreement and Principal *Include any accounts/resources which may have been closed, cashed in, or transferred within the past 60 months *Income Tax returns, including 1099s (5 years) *Financial summary of any private payments made to a nursing home. *Verification and Clarification of any withdrawals or deposits over $2000 (copy of cancelled checks) deposit receipts LIFE INSURANCE: *Assessed value of house/property either current OR transferred within last 5 years *Copy of policy and verification of cash value, name of owner and policy number HEALTH INSURANCE: *Medicare Card *Identification Card for Health Insurance *Premium Amount *Proof of Payment VETERAN STATUS: *Military Discharge papers for applicant or spouse OTHER DOCUMENTS: *Copy of Power of. Attorney *Signed Authorization to represent form *Guardianship Papers *Itemized Irrevocable Burial Trust or Pre-need Agreement-(PAID IN FULL) THE GRAND REHABILITATION AND NURSING AT SOUTH POINT MOHAWK LIST OF ADDENDA

Resources. Where your name or your *Any property that you owned within the last 60 months spouse’s name may be listed *Passbooks, bank statements (opened and closed accounts for the past 60 months) *Stocks, Bonds, Annuities *Investments/Brokerage Funds *Certificates of Deposit (CDs), Credit Union accounts, IRAs *Trust Agreement and Principal *Include any accounts/resources which may have been closed, cashed in, or transferred within the past 60 months *Income Tax returns, including 1099s (5 years) *Financial summary of any private payments made to a nursing home. *Verification and Clarification of any withdrawals or deposits over $2000 (copy of cancelled checks) deposit receipts LIFE INSURANCE: *Assessed value of house/property either current OR transferred within last 5 years *Copy of policy and verification of cash value, name of owner and policy number HEALTH INSURANCE: *Medicare Card *Identification Card for Health Insurance *Premium Amount *Proof of Payment VETERAN STATUS: *Military Discharge papers for applicant or spouse OTHER DOCUMENTS: *Copy of Power of. Attorney *Signed Authorization to represent form *Guardianship Papers *Itemized Irrevocable Burial Trust or Pre-need Agreement-(PAID IN FULL) THE GRAND REHABILITATION AND NURSING AT SOUTH POINT DELAWARE PARK LIST OF ADDENDA

Resources. Where your name or your *Any property that you owned within the last 60 months spouse’s name may be listed *Passbooks, bank statements (opened and closed accounts for the past 60 months) *Stocks, Bonds, Annuities *Investments/Brokerage Funds *Certificates of Deposit (CDs), Credit Union accounts, IRAs *Trust Agreement and Principal *Include any accounts/resources which may have been closed, cashed in, or transferred within the past 60 months *Income Tax returns, including 1099s (5 years) *Financial summary of any private payments made to a nursing home. *Verification and Clarification of any withdrawals or deposits over $2000 (copy of cancelled checks) deposit receipts LIFE INSURANCE: *Assessed value of house/property either current OR transferred within last 5 years *Copy of policy and verification of cash value, name of owner and policy number HEALTH INSURANCE: *Medicare Card *Identification Card for Health Insurance *Premium Amount *Proof of Payment VETERAN STATUS: *Military Discharge papers for applicant or spouse OTHER DOCUMENTS: *Copy of Power of. Attorney *Signed Authorization to represent form *Guardianship Papers *Itemized Irrevocable Burial Trust or Pre-need Agreement-(PAID IN FULL) THE GRAND REHABILITATION AND NURSING AT SOUTH POINT XXXXXXXX LIST OF ADDENDA

Resources. Where your name or your *Any property that you owned within the last 60 months spouse’s name may be listed *Passbooks, bank statements (opened and closed accounts for the past 60 months) *Stocks, Bonds, Annuities *Investments/Brokerage Funds *Certificates of Deposit (CDs), Credit Union accounts, IRAs *Trust Agreement and Principal *Include any accounts/resources which may have been closed, cashed in, or transferred within the past 60 months *Income Tax returns, including 1099s (5 years) *Financial summary of any private payments made to a nursing home. *Verification and Clarification of any withdrawals or deposits over $2000 (copy of cancelled checks) deposit receipts LIFE INSURANCE: *Assessed value of house/property either current OR transferred within last 5 years *Copy of policy and verification of cash value, name of owner and policy number HEALTH INSURANCE: *Medicare Card *Identification Card for Health Insurance *Premium Amount *Proof of Payment VETERAN STATUS: *Military Discharge papers for applicant or spouse OTHER DOCUMENTS: *Copy of Power of. Attorney *Signed Authorization to represent form *Guardianship Papers *Itemized Irrevocable Burial Trust or Pre-need Agreement-(PAID IN FULL) THE GRAND REHABILITATION AND NURSING AT SOUTH POINT QUEENS LIST OF ADDENDA

Resources. Where your name or your *Any property that you owned within the last 60 months spouse’s name may be listed *Passbooks, bank statements (opened and closed accounts for the past 60 months) *Stocks, Bonds, Annuities *Investments/Brokerage Funds *Certificates of Deposit (CDs), Credit Union accounts, IRAs *Trust Agreement and Principal *Include any accounts/resources which may have been closed, cashed in, or transferred within the past 60 months *Income Tax returns, including 1099s (5 years) *Financial summary of any private payments made to a nursing home. *Verification and Clarification of any withdrawals or deposits over $2000 (copy of cancelled checks) deposit receipts LIFE INSURANCE: *Assessed value of house/property either current OR transferred within last 5 years *Copy of policy and verification of cash value, name of owner and policy number HEALTH INSURANCE: *Medicare Card *Identification Card for Health Insurance *Premium Amount *Proof of Payment VETERAN STATUS: *Military Discharge papers for applicant or spouse OTHER DOCUMENTS: *Copy of Power of. Attorney *Signed Authorization to represent form *Guardianship Papers *Itemized Irrevocable Burial Trust or Pre-need Agreement-(PAID IN FULL) THE GRAND REHABILITATION AND NURSING AT SOUTH POINT CHITTENANGO LIST OF ADDENDA

Resources. Where your name or your *Any property that you owned within the last 60 months spouse’s name may be listed *Passbooks, bank statements (opened and closed accounts for the past 60 months) *Stocks, Bonds, Annuities *Investments/Brokerage Funds *Certificates of Deposit (CDs), C.D.s Credit Union accountsUnion, IRAs *Trust Agreement and Principal *Include any accounts/resources which may have been closed, cashed in, or transferred within the past 60 months *Income Tax returns, including 1099s (5 years) *Financial summary of any private payments made to a nursing home. *Verification and Clarification of any withdrawals or deposits over $2000 (copy of cancelled checks) deposit receipts LIFE INSURANCE: *Assessed value of house/property either current OR Or transferred within last 5 years *Copy of policy and verification of cash value, name of owner and policy number HEALTH INSURANCE: *Medicare Card *Identification Card for Health Insurance *Premium Amount *Proof of Payment VETERAN STATUS: *Military Discharge papers for applicant or spouse OTHER DOCUMENTS: *Copy of Power of. Attorney *Signed Authorization to represent form *Guardianship Papers *Itemized Irrevocable Burial Trust or Pre-need Agreement-(PAID IN FULL) THE GRAND REHABILITATION AND NURSING AT SOUTH POINT LIST IDENTITY/PROOF OF ADDENDABIRTH: Two of the following: *Birth Certificate *Baptismal Certificate *Driver License *U.S. Passport U.S. CITIZENSHIP: Provide one of the following: *Naturalization Certificate *U.S. Passport *Permanent Resident Card *Voter Registration Card SOCIAL SECURITY NUMBER Provide one of the following: *Social Security Card/Application for duplicate (copy) *Printout from Social Security — TPQY Administration MARITAL STATUS: Provide one of the following: *Marriage Certificate *Legal Separation Agreement *Divorce Degree *Spouse's Death Certificate RESIDENCE: Provide one of the following: *Deed, Lease or Rent Receipt *Residence prior to admission to Nursing home must be verified INCOME: *(EARNED) 4 most current pay stubs if weekly, 2 stubs if bi-weekly *(UNEARNED) *Copy of Social Security Check or TPQY *Pension Check and. Stub (must verify gross amount) *Interest, Dividends, Annuities, Partnerships, Rental Income

Resources. Where your name or your *Any property that you owned within the last 60 months spouse’s name may be listed *Passbooks, bank statements (opened and closed accounts for the past 60 months) *Stocks, Bonds, Annuities *Investments/Brokerage Funds *Certificates of Deposit (CDs), Credit Union accounts, IRAs *Trust Agreement and Principal *Include any accounts/resources which may have been closed, cashed in, or transferred within the past 60 months *Income Tax returns, including 1099s (5 years) *Financial summary of any private payments made to a nursing home. *Verification and Clarification of any withdrawals or deposits over $2000 (copy of cancelled checks) deposit receipts LIFE INSURANCE: *Assessed value of house/property either current OR transferred within last 5 years *Copy of policy and verification of cash value, name of owner and policy number HEALTH INSURANCE: *Medicare Card *Identification Card for Health Insurance *Premium Amount *Proof of Payment VETERAN STATUS: *Military Discharge papers for applicant or spouse OTHER DOCUMENTS: *Copy of Power of. Attorney *Signed Authorization to represent form *Guardianship Papers *Itemized Irrevocable Burial Trust or Pre-need Agreement-(PAID IN FULL) THE GRAND REHABILITATION AND NURSING AT SOUTH POINT PAWLING LIST OF ADDENDA

Resources. Where your name or your *Any property that you owned within the last 60 months spouse’s name may be listed *Passbooks, bank statements (opened and closed accounts for the past 60 months) *Stocks, Bonds, Annuities *Investments/Brokerage Funds *Certificates of Deposit (CDs), Credit Union accounts, IRAs *Trust Agreement and Principal *Include any accounts/resources which may have been closed, cashed in, or transferred within the past 60 months *Income Tax returns, including 1099s (5 years) *Financial summary of any private payments made to a nursing home. *Verification and Clarification of any withdrawals or deposits over $2000 (copy of cancelled checks) deposit receipts LIFE INSURANCE: *Assessed value of house/property either current OR transferred within last 5 years *Copy of policy and verification of cash value, name of owner and policy number HEALTH INSURANCE: *Medicare Card *Identification Card for Health Insurance *Premium Amount *Proof of Payment VETERAN STATUS: *Military Discharge papers for applicant or spouse OTHER DOCUMENTS: *Copy of Power of. Attorney *Signed Authorization to represent form *Guardianship Papers *Itemized Irrevocable Burial Trust or Pre-need Agreement-(PAID IN FULL) THE GRAND REHABILITATION AND NURSING AT SOUTH POINT Maple City Rehabilitation & Nursing Center LIST OF ADDENDA

Resources. Where your name or your *Any property that you owned within the last 60 months spouse’s name may be listed *Passbooks, bank statements (opened and closed accounts for the past 60 months) *Stocks, Bonds, Annuities *Investments/Brokerage Funds *Certificates of Deposit (CDs), Credit Union accounts, IRAs *Trust Agreement and Principal *Include any accounts/resources which may have been closed, cashed in, or transferred within the past 60 months *Income Tax returns, including 1099s (5 years) *Financial summary of any private payments made to a nursing home. *Verification and Clarification of any withdrawals or deposits over $2000 (copy of cancelled checks) deposit receipts LIFE INSURANCE: *Assessed value of house/property either current OR transferred within last 5 years *Copy of policy and verification of cash value, name of owner and policy number HEALTH INSURANCE: *Medicare Card *Identification Card for Health Insurance *Premium Amount *Proof of Payment VETERAN STATUS: *Military Discharge papers for applicant or spouse OTHER DOCUMENTS: *Copy of Power of. Attorney *Signed Authorization to represent form *Guardianship Papers *Itemized Irrevocable Burial Trust or Pre-need Agreement-(PAID IN FULL) THE GRAND REHABILITATION AND NURSING AT SOUTH POINT ROME LIST OF ADDENDA

Resources. Where your name or your *Any property that you owned within the last 60 months spouse’s name may be listed *Passbooks, bank statements (opened and closed accounts for the past 60 months) *Stocks, Bonds, Annuities *Investments/Brokerage Funds *Certificates of Deposit (CDs), C.D.s Credit Union accountsUnion, IRAs *Trust Agreement and Principal *Include any accounts/resources which may have been closed, cashed in, or transferred within the past 60 months *Income Tax returns, including 1099s (5 years) *Financial summary of any private payments made to a nursing home. *Verification and Clarification of any withdrawals or deposits over $2000 (copy of cancelled checks) deposit receipts LIFE INSURANCE: *Assessed value of house/property either current OR Or transferred within last 5 years *Copy of policy and verification of cash value, name of owner and policy number HEALTH INSURANCE: *Medicare Card *Identification Card for Health Insurance *Premium Amount *Proof of Payment VETERAN STATUS: *Military Discharge papers for applicant or spouse OTHER DOCUMENTS: *Copy of Power of. Attorney *Signed Authorization to represent form *Guardianship Papers *Itemized Irrevocable Burial Trust or Pre-need Agreement-(PAID IN FULL) THE GRAND REHABILITATION AND NURSING AT SOUTH POINT LIST OF ADDENDAI understand that as part of my health care, the Facility and the physician(s) who care for me originate and maintain health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information serves as a basis for planning my care and treatment, to arrange for the billing and payment of my care and to carry out routine health care operations, such as assessing quality.

Resources. Where your name or your *Any property that you owned within the last 60 months spouse’s name may be listed *Passbooks, bank statements (opened and closed accounts for the past 60 months) *Stocks, Bonds, Annuities *Investments/Brokerage Funds *Certificates of Deposit (CDs), Credit Union accounts, IRAs *Trust Agreement and Principal *Include any accounts/resources which may have been closed, cashed in, or transferred within the past 60 months *Income Tax returns, including 1099s (5 years) *Financial summary of any private payments made to a nursing home. *Verification and Clarification of any withdrawals or deposits over $2000 (copy of cancelled checks) deposit receipts LIFE INSURANCE: *Assessed value of house/property either current OR transferred within last 5 years *Copy of policy and verification of cash value, name of owner and policy number HEALTH INSURANCE: *Medicare Card *Identification Card for Health Insurance *Premium Amount *Proof of Payment VETERAN STATUS: *Military Discharge papers for applicant or spouse OTHER DOCUMENTS: *Copy of Power of. Attorney *Signed Authorization to represent form *Guardianship Papers *Itemized Irrevocable Burial Trust or Pre-need Agreement-(PAID IN FULL) THE GRAND REHABILITATION AND NURSING AT SOUTH POINT LIST OF ADDENDA)

Resources. Where your name or your *Any property that you owned within the last 60 months spouse’s name may be listed *Passbooks, bank statements (opened and closed accounts for the past 60 months) *Stocks, Bonds, Annuities *Investments/Brokerage Funds *Certificates of Deposit (CDs), Credit Union accounts, IRAs *Trust Agreement and Principal *Include any accounts/resources which may have been closed, cashed in, or transferred within the past 60 months *Income Tax returns, including 1099s (5 years) *Financial summary of any private payments made to a nursing home. *Verification and Clarification of any withdrawals or deposits over $2000 (copy of cancelled checks) deposit receipts LIFE INSURANCE: *Assessed value of house/property either current OR transferred within last 5 years *Copy of policy and verification of cash value, name of owner and policy number HEALTH INSURANCE: *Medicare Card *Identification Card for Health Insurance *Premium Amount *Proof of Payment VETERAN STATUS: *Military Discharge papers for applicant or spouse OTHER DOCUMENTS: *Copy of Power of. Attorney *Signed Authorization to represent form *Guardianship Papers *Itemized Irrevocable Burial Trust or Pre-need Agreement-(PAID IN FULL) THE GRAND REHABILITATION AND NURSING AT SOUTH POINT RIVER VALLEY LIST OF ADDENDA