Financial Resident Funds Record

Financial Resident Funds Record

Facility Information

Resident Information

Resident Name:   ID / Account No.:

Date of Birth:   Room / Unit:

Record Details

Record Number:   Record Date:   Intake Staff:

Legal Acknowledgment and Terms

The Facility acknowledges receipt of funds held on behalf of the resident in a fiduciary capacity. Funds deposited will be accounted for in the ledger below, retained in accordance with the Facility's safekeeping procedures, and disbursed only upon written authorization from the resident or the resident's authorized representative, or as permitted by law. The Facility will maintain receipts and a running balance and will provide statements upon request. The Facility's liability for loss is limited to proven negligence or willful misconduct; the Facility is not responsible for market losses incurred from investments unless expressly authorized in writing.

Interest: Funds held in interest-bearing accounts will accrue interest according to Facility policy. Any administrative fee for holding or disbursing funds will be disclosed and deducted only with written notice. Withdrawals may require advance notice; emergency disbursements will be processed in accordance with Facility procedures. Discharge or transfer of the resident will trigger final accounting and settlement of remaining funds within a reasonable period.

Transaction Ledger

Authorizations and Notices

By checking the box below and signing this record the resident or authorized representative authorizes the Facility to hold funds in custody, to apply such funds to charges for services or care rendered to the resident in accordance with documented charges, and to disburse funds upon written request or as required by statute. This authorization does not permit the Facility to invest resident funds except as stated in a separate written agreement.

I authorize the Facility to use funds for resident charges as described above.

I acknowledge receipt of a copy of the Facility's Resident Funds Policy and understand the fees, notice requirements, and limits described therein.

Record Certification

The undersigned certify that the information recorded on this Financial Resident Funds Record is accurate to the best of their knowledge. Facility personnel will retain copies of receipts and supporting documentation and will make them available upon lawful request. Any discrepancies must be reported in writing within 30 days of the statement date.

Facility Contact for Questions:   Phone:

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