City of Falls
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Assisted Living Interest List Application
Housing and Human Services
300 Park Avenue, Falls Church, Virginia
22046
703-248-5005, TTY
711
hsinfo@fallschurchva.gov
Please indicate which low and moderate income program you are interested in: (check both if applicable)
Sunrise Set-Aside The Kensington Subsidized Program
APPLICANT’S INFORMATION
___________________________________ ________________________ Male Female
First Name Last Name
_________________________________________________________________ _____________________________
Address Date of Birth
___________________________ __________ ________________ ___________________________________
City State Zip Code Home Phone
____________________________________________
E-Mail
Gross annual income from all sources:________________________________________________________________
Assets, including home equity (The Kensington applicant only):______________________________________________
Annual health care premiums: __________________________________________________________________
CONTACT PERSON (if different from applicant)
___________________________________ ________________________ _____________________________
First Name Last Name Relationship to Applicant
_________________________________________ ________________ ____________ ____________________
Address (if different from above) City State Zip Code
______________________________ ____________________________ ______________________________
Home Phone Work Phone Cell Phone
____________________________________________
E-Mail
I certify that the above information is correct:
_________________________________________________ __________________________
Signature Date
Information furnished to the City of Falls Church Housing and Human Services Division will be maintained and disseminated for governmental purposes
in accordance with the Virginia Freedom of Information Act, Code of Virginia, Section 2.1.340 through 346.1 as amended, and the Privacy Protection Act
of 1976, Code of Virginia Sections, 2.1-377 through 386, as amended. The City of Falls Church does not discriminate on the basis of disability in its
employment practices or in the admission to, access to, or operations of its services, programs, or activities. Cindy Mester, 300 Park Avenue, Falls
Church, Virginia 22046 has been designated to coordinate compliance with the ADA non-discrimination requirement.
