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Self-Funding Financial Assessment
Savings
£
Pounds
Investments
£
Pounds
Bonds
£
Pounds
Property
£
Pounds
Sum of total assets
*
£
Pounds
Regular Yearly Income
£
Pounds
Declaration
I/we declare that this financial self-assessment is a true statement of my assets, and shows my ability to fund my stay at Derbyshire House residential care home for a minimum of five years.
Name: Prospective Resident
*
Name: Authorised Representative
Name: Person with Power of Attorney