Residential Application

Email address

Your name in full

Your complete address

City

State

Zip

Telephone Number

SSN

Your date of birth

Age

Sex

Birthplace

Of which country are you a citizen?

If your citizenship is other than the United States, are you able to obtain a permanent United States resident visa? (Please type yes / no or Don't know)

Are you married, widowed, divorced or single?

How long have you been practicing Christian Science?

How long have you served actively as a
Christian Science Journal listed practitioner,
or as a
Christian Science Journal listed nurse?

List years

Does your listing appear now? Yes No

If your listing in The Journal has ever withdrawn and removed, kindly explain fully :

When did you receive Christian Science primary class instruction ?

Who was your Christian Science primary class teacher? , C.S.B

When did you first join the Mother Church, The First Church of Christ , Science in Boston, Massachusetts? (please enter year)

Which branch Church or Society do you belong to?
Since (year joined)

Please list the last three Branch Churches or Societies of which you have been a member, year joined, and reason for change:
a)
b)
c)

Would you list the various capacities in which you have served the Church of Christ, Scientist over the years?

Do you intend to continue active Branch Church participation?
Yes
No

Please describe your general condition of health :

Do you have any physical disabilities or disorders?
Yes No

If yes, please describe the nature of them :

Are you able to take care of normal living needs (marketing, cooking, housekeeping) without assistance ?
Yes No

If no, please state why:

It is assumed as a working Christian Scientist that you are free from the use of tobacco , drugs and intoxicants. Is this a correct assumption?
Yes No

My Current Income

My monthly income from social security, company, government, institutional, or other sources is:
1.

My monthly income from the interest of savings, money market funds, and bonds is:
2.

My monthly income from dividends of stocks or mutual funds is;
3.

My monthly income from rental property I own is:
4.

My monthly income from Christian Science practice/work is:
5.

My monthly income from the support of family members is:
6.

My monthly income from from other sources is/are (identify):

Sub Total
8.

Add line 1 through 7

Do you expect any of the above income to cease within the near future?
Yes No

If "yes," deduct the monthly amount from the Sub Total. Explain the reduction:

Total Monthly Income

10.

Subtract 9 from 8

My Expenses Are

My monthly rent or mortgage payment is: 1.

My monthly food expenses are: 2.

My monthly transportation expenses are: 3.

My monthly insurance expenses are: 4.

My other monthly miscellaneous expenses are: 5.

My total monthly expenses are: 6.

Add 1 through 5

My Assets Are

The estimated value of property I own is: 1.

The estimated value of mutual funds, stocks or bonds I hold is: 2.

The amount I have in savings , checking, money market funds or certificates of deposit is: 3.

The estimated value of my automobile(s) is/are: 4.

The value of all other assets I hold are estimated to be: 5.

The total value of my assets is: 6.

Subtract 9 from 8

My Current Debts Are
(Please disclose any present indebtedness in excess of $1,000 U.S.)

Creditor

Amounts

My monthly income from the interest of savings, money market funds, and bonds is:

My total debts in excess of $1,000 U.S. are:

Add line 1 through 3

Concerning My Personal Banking And Financial Affairs

At present, do you handle all of your own personal banking and financial affairs?
Yes No

If no, who does handle these affairs for you?

Comments

Please comment on anything in this application you may wish to explain or discuss further:

Why are you interested in coming to Mankowski Homes?:

If A Special Need Arose
Names of those (including children) who would help if an emergency or special need arose.

Name:

Telephone:

Address:

City:

Name:

Telephone:

Address:

City:

Name:

Telephone:

Address:

References
Please list three (3) members of The Mother Church who are not related to you, including one (1) advertised Christian Science Practitioner acquainted with your affairs and to whom reference may be made: (Please list Practitioners first.)

Practitioners Name:

Telephone:

Address:

City:

How Acquainted:

Practitioners Name:

Telephone:

Address:

City:

How Acquainted:

Practitioners Name:

Telephone:

Address:

How Acquainted:

Verification /Approval Signature

The WINIFRED STUART MANKOWSKI HOMES consist of separate bungalow-apartments, each complete with a kitchen, where the residents can prepare their own meals. They will also do their own housework except for a periodic general cleaning service. No central dining room or nursing facility is provided. There is, in the Administration Building a library and a social-lounge room for the enjoyment of the residents. In addition, a laundry room with washers and dryers is also available.

Are these living arraignments acceptable to you? Yes No

I thoroughly understand the questions and answers in this application and if accepted as a resident will, as a working Christian Scientist do everything possible to support the purpose and aims of the WINIFRED STUART MANKOWSKI HOMES in the promotion of an enlightened sense of advancing years for the other residents as well as for myself. I also understand that if accepted for tenancy, it will be on a monthly rental basis to continue as long as I demonstrate the capacity to live independently and harmoniously support the rules of the Homes, the terms of the MANKOWSKI TRUST, and the general good of all who reside in the Homes.

I hereby grant permission to the WINIFRED STUART MANKOWSKI FOUNDATION and its agents to contact the references and to verify such information as is deemed necessary to process this application. I further attest to the fact that all I have stated in this application is correct to the best of my knowledge and belief.

By selecting the submit button, you agree to all terms and provisions stated in this document.