APPLICATIONS 2019/2020 (June – May) (The application is valid for one year from date of receipt) • The forms are available from the offices of Badisa Knysna for a non-refundable, once off. administrative fee of R70.00 • The application must be completed in full otherwise it will not be processed • The financial declaration must be certified by a Commissioner of Oaths. Please note that there is no such service available at Loeriehof. • Tariffs are valid from 1 June – 31 May and financial declarations must be submitted annually. Tariffs are adjusted annually with approximately 10% per annum. • The medical practitioner’s report may only be completed by a qualified, certified medical practitioner or clinic nursing sister. • The Department of Social Development is responsible for the Social Worker report and can be contacted at 044 382 0056 for the Social Worker report that has to accompany the application. • All applications are subject to a selection process that may include a home visit from a Nurse and/or Social Worker. • Please Note: Loeriehof has limited subsidized space available for lower income applicants • Please note that selections are done as space becomes available in the Home, but enquiries are welcome at any time • Flat rental is R4 900.00 per month for a single flat; R6 100.00 for a double flat and includes lunch, weekly cleaning and weekly laundry service. • Skoolhuis rooms are R1 310.00 per month per room en includes daily lunch, weekly cleaning of rooms, access to a washing machine and monthly clinic at Loeriehof. • Assisted Living costs R7 260.00 per month which includes all meals, tea/coffee, weekly cleaning of rooms, laundry and access to care staff. • Frail Care costs R7 700.00 per month and includes all meals, coffee/tea, cleaning and laundry service with preferred access to care staff.
20
Embed
APPLICATIONS 2019/2020 (June (The application is valid for one … application with information pack 2019.2020.pdf · APPLICATIONS 2019/2020 (June – May) (The application is valid
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
APPLICATIONS 2019/2020 (June – May)
(The application is valid for one year from date of receipt)
• The forms are available from the offices of Badisa Knysna for a non-refundable, once off. administrative fee of R70.00
• The application must be completed in full otherwise it will not be processed
• The financial declaration must be certified by a Commissioner of Oaths. Please note that there is no such service available at Loeriehof.
• Tariffs are valid from 1 June – 31 May and financial declarations must be submitted annually. Tariffs are adjusted annually with approximately 10% per annum.
• The medical practitioner’s report may only be completed by a qualified, certified medical practitioner or clinic nursing sister.
• The Department of Social Development is responsible for the Social Worker report and can be contacted at 044 382 0056 for the Social Worker report that has to accompany the application.
• All applications are subject to a selection process that may include a home visit from a Nurse and/or Social Worker.
• Please Note: Loeriehof has limited subsidized space available for lower income applicants
• Please note that selections are done as space becomes available in the Home, but enquiries are welcome at any time
• Flat rental is R4 900.00 per month for a single flat; R6 100.00 for a double flat and includes lunch, weekly cleaning and weekly laundry service.
• Skoolhuis rooms are R1 310.00 per month per room en includes daily lunch, weekly cleaning of rooms, access to a washing machine and monthly clinic at Loeriehof.
• Assisted Living costs R7 260.00 per month which includes all meals, tea/coffee, weekly cleaning of rooms, laundry and access to care staff.
• Frail Care costs R7 700.00 per month and includes all meals, coffee/tea, cleaning and laundry service with preferred access to care staff.
Frail Care
FACILITY: LOERIEHOF HOME FOR THE ELDERLY Assisted Living
7. Fixed property, e.g. farms, dwellings (Full description and where situated)
Municipal assessment
Bond in arrears
Monthly income
Self Spouse
7.1
7.2
8. Other sources if income, e.g. income from business usufruct/Fidei Commissum (Please specify)
Self Spouse
8.1
8.2
8.3
TOTAL R
2
B. TOTAL VALUE OF ASSETS SOLD AND DONATIONS MADE OVER THE LAST 10 YEARS (Please specify) 1. Did you sell or donate any assets (fixed property) during the past ten (10) years? If so, please
give the following details:
[a] Assets sold (description)
[i] Date sold
[ii] Bruto amount received R
[iii] Minus selling costs (please specify on separate page) R
Nett income R
[b] Assets donated (description)
[i] Date donated
[ii] Amount donated R
[c] Cash donated (description)
[i] Date donated
[ii] Amount donated R
2. EXPENDITURE OF A CONTINUOUS NATURE (Documentary proof of expenditure must be
furnished) Specify e.g. medical fund, subscription fees, municipal tax, installments, etc in the case of property:
2.1 R
2.2 R
2.3 R
TOTAL R
I hereby declare that the information furnished by me, is to the best of my knowledge, true and correct and
that the declared income the total income of the applicant is for the _______________tax year.
SIGNATURE OF APPLICANT/AUTHORISED PERSON
DATE
NB: All interest revenue must be certified per certificate of balance by financial institutions.
A false declaration is a punishable offence.
3
DECLARATION I certify that, before administering the oath/affirmation, I asked the deponent the following questions and wrote down his/her answers in his/her presence: [a] Do you know and understand the contents of the declaration? Answer: _______________ [b] Do you have any objection in taking the prescribed oath? Answer: _______________ [c] Do you consider the prescribed oath to be binding on your conscience? Answer: _______________ I certify that the deponent has acknowledged that he/she knows and understands the contents of this declaration which has sworn to/affirmed before me and the deponent’s signature/thumb print/mark was placed thereon in my presence.
COMMISSIONER OF OATHS PLACE
DATE
FOR OFFICIAL USE
Nett income R
Boarding per month R
Officer employed by the Department of Social Development
Date
FOR OFFICIAL USE BY A SCREENING OFFICER OF THE DEPARTMENT OF SOCIAL DEVELOPMENT
Gross income R
Minus approved expenditure (specify)
[a] R
[b] R
[c] R
[d] R
Nett income R
Income group code
1
1. FULL NAME AND SURNAME: _____________________________________ 2. AGE: __________________ 3. OVERVIEW OF APPLICANT’S MEDICAL HISTORY EN PREVIOUS