What type of care are you applying for?
Possible future date for permanent care
How did you hear about Residency by Dillons?
Applicant’s Details
Who is your Home Care Provider:
If you confirmed "Yes" that you currently have a funded home care package, please fill in details below
Current Home Address (not Hospital or TCP address)
Are you coming to Residency by Dillons from:
Please enter details regarding specific room or room type.
Contact 1
Contact 2 (Not Mandatory)
Responsibilities
Current Medical Practitioner (GP)
Private Health Insurance
Ambulance Fund
Pension/Medicare
Vaccinations
Income and Assets
Please attach assessment from Services Australia. (You will be able to do this at the end of this form)
Income and Assets Assessment
TYPE OF INCOME PER ANNUM
Income support payment from the Australian Government (eg. Age Pension)
War Widow or Widow Pension/Disability Pension/Carer’s Pension
Overseas Pension(s)
Superannuation
Income from rental properties, business(es), family trust(s), or other, excluding bank interest
ASSETS
Home (Estimated Net Market Value) If not occupied by Protected Person
Savings in Bank Account
Stocks/Shares
Term Deposits
Managed Investments (Superannuation Balance if income stream not commenced)
Gifting Assets (if you have gifted away amounts above $10,000 in the last year, or $30,000 in the last five years, or gifted your home, include anything above these amounts here as a financial asset)
OTHER ASSETS
Household Contents (typically around $10,000), Car, Caravan, etc.
Superannuation Balance (if commenced as an income stream)
Net Retirement Village Entry Contributions/Trust
Investment Properties (must match income from rental properties)
Other Assets (provide details)
FILE UPLOADS