b'PREQUALIFICATION WORKSHEETSTEP 1: PERSONAL INFORMATIONSERVICES Date ________________ Desired Residence Type _______________________Person #1 Name ___________________ Age _____ Gender _____ ZIP_______Person #2 Name ___________________ Age _____ Gender _____ ZIP _______Do you have long-term care (LTC) insurance?[ ] Yes [ ] NoIf yes:1. How many years does the LTC policy last? ________________________2. How many days before the LTC policy begins? ____________________3. What is the assisted living daily benet? _________________________4. What is the skilled nursing daily benet? _________________________5. What is the annual premium for Person #1? _______________________6. What is the annual premium for Person #2? _______________________STEP 2: ASSETS AND DEBTSOURCES OF INCOME (Enter monthly net amounts)Home Value$___________ Cash$___________ Social Security Person #1$___________Stocks and Bonds$___________ Social Security Person #2$___________IRA/401(k) Person #1$___________ Pension Person #1$___________IRA/401(k) Person #2$___________[] COLA1 [] Survivor BenetOther Assets$___________ Pension Person #2$___________ Mortgage$___________ [] COLA1 [] Survivor Benet Home Equity Loan$___________ Withdrawals (IRA/401(k))$___________Other Debt$___________ Person #1$___________Person #2$___________Other Monthly Income $___________LEGAL:Please note: This worksheet is not a nancial qualier that will either approveEXPLORING YOUR OPTIONS or deny your residency. Should you wish to proceed and apply for residency,well ask you to ll out a comprehensive (and completely condential)nancial worksheet, tear it out, and bring it with you when you visit our community.If youre considering Trillium Woods, it could be more affordable than_____________________________________________you think. Find out for yourself by completing our simple prequalicationApplicantworksheet on the next page. Upon review, our team will determine what additional information may be needed for your nancial qualication. _____________________________________________Sales Counselor14 15'