Statement of Occupancy form?

Discussion in 'How to Apply Questions' started by Karenforjoe, Sep 6, 2017.

  1. Karenforjoe

    Karenforjoe Newbie

    My 92 year old step-dad is now in assisted living as my 87 year old mom can no longer take care of the house, meals, and yard. Can you help me find the Statement of Occupancy as our assisted living facility does not have one. Thank you.
  2. Kaylin

    Kaylin Hero Member Staff Member

    Hmm, I can't seem to find an example of one. @Matt375 do you happen to have an example of a Statement of Occupancy? Just a general template she can use?
  3. Honor First

    Honor First Newbie

    All I could find was a VA Form 10-1170 "Application for Furnishing Nursing Home Care?"

    I'm not sure what you are looking for, but in the recent case of my brother's approval for A&A all we submitted was a letter from the senior care center, which explained the services they were providing i.e.:safety/security; administering medications, transportation to doctor appointments, prepared meals, laundry etc...

    This was sufficient for approval of the application.
    Kaylin likes this.
  4. Bishop16

    Bishop16 Newbie

    I have the form you are looking for. I am not sure how to get it to you! You can email me at Vreeves and I can scan it to you or email as an attachment!
    Kaylin likes this.
  5. Bishop16

    Bishop16 Newbie

    Try this ! This is what we use!

    Attached Files:

    Kaylin likes this.
  6. jscott

    jscott Jr. Member

    For my MIL's packet, I prepared this letter for the Statement of Occupancy and asked the business manager to put it on their official letterhead and sign it. She was VERY happy I drafted the letter for her:

    (Use official letterhead)


    Subject: Statement of Occupancy for (resident's name):

    To Whom It May Concern:

    (Resident name) became a resident at (Name of Facility) on (move-in date).

    Her monthly rate is $X,XXX, which includes 15 hours of personal care services. These services include assistance with activities of daily living, such as bathing, dressing, mobility, housekeeping, and medication management. (Obviously, if yours are different, then describe similarly)

    If additional information is required, contact me by phone (xxx-xxx-xxxx) or email (manager's email address)

    (Original signature)

    Signature block of official (like the business manager)

    This worked for me -- hope this helps you.
    Kaylin likes this.
  7. Kaylin

    Kaylin Hero Member Staff Member

Share This Page