NAME AND ADDRESS OF PROVIDER | (1) |
OFFICERS, DIRECTORS, AND TRUSTEES | (2) |
BUSINESS EXPERIENCE | (3) |
JUDICIAL PROCEEDINGS | (4) |
AFFILIATION | (5) |
DESCRIPTION OF PROPERTY | (6) |
BENEFITS INCLUDED | (7) |
INTEREST ON DEPOSITS | (8) |
TERMINATION OF CONTRACT | (9) |
RIGHTS OF A SURVIVING SPOUSE | (10) |
MARRIAGE OF A RESIDENT | (11) |
DISPOSITION OF PERSONAL PROPERTY | (12) |
TAX CONSEQUENCES | (13) |
RESERVE FUNDING - ESCROWS | (14) |
FINANCIAL STATEMENTS | (15) |
SOURCE OF FUNDS (if facility is not in operation) | (16) |
PRO FORMA INCOME STATEMENTS | (17) |
ENTRANCE FEES/PERIODIC CHARGES | (18) |
PRE-PAID OBLIGATIONS, ACTUARIAL VALUE | (19) |
DEPARTMENT ON AGING - FILINGS | (20) |
CONTINUING-CARE CONTRACT | (21) (c) |
Conn. Agencies Regs. § 17b-533-3