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Fill out the form below for FREE housing information
Full Name : *
Address: *
Day Time Phone No. *   
Cell:  
Night Time Phone No. *   
Fax:  
Email :
Your relationship to the senior or adult:

Select Area of Choice:
San Bernardino County Riverside County
Orange County Los Angeles County

Select Price Range: *
SSI $1,000-$2,000 $2,000-$3,000
$3,000-4,000 Over $4,000  

Type of Accomodation:
Private Shared Either  

Loan Type:
(Check all that apply)
Assisted Living Communities
Alzheimer’s/Dementia Care
Housing Loan
Residential Care Facilities
(AKA Board and Care)
Business
Retirement Homes
Mobile Homes

Your Name :
*
Age: *   
Sex: *

Loan Type
Home Refinance
Home Purchase
Home Equity
Business Loan
COPD
Loan
Education Loan
Other
Other
   

Other (List Other Health Issues):

What does your senior or adult need help with:
Bathing
Dressing
Medications
Ambulation
Grooming
 

Credit Profile
Excellent
Fair
Poor
Bad
Ok
n/a

Do you want a loan?
No Yes    

Home Description
Single Family  
Condo  
Townhouse  

Does your senior / adult have:
Paraphlegia  
Hemiphlegia  
Quadraphlegia  

If you have any other information you would like to share with us to better help you the appropriate facility, please enter it below: