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Life Plan Communities Forms



Form #GID-059-NT This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2015
Title: Life Plan Communities and Facility Biographical Affidavit
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.
PID:629-SID:995-FN:GID-059-EN.pdf

Form #GID-060-NT This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2015
Title: Annual Statement for Life Plan Communities and Facility
This form is completed annually for the Provider and the Facility. Included are three parts to this form comprising general interrogatories and the statement of financial condition. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.
PID:632-SID:998-FN:GID-060-EN.pdf

Form #GID-061-NT Instructions Letter This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2012
Title: Instructions For Application For Certificate Of Authority As A Life Plan Communities
This document explains the requirements for making Application For Certificate Of Authority As A Life Plan Communities.
PID:627-SID:993-FN:GID-061.pdf

Form #GID-276-EN This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2015
Title: Citizenship Affidavit
Effective 1-1-2012, this form is required of persons making application for all licenses, permits, registrations and certifications in order to comply with the Georgia Illegal Immigration Reform And Enforcement Act. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.
PID:788-SID:1688-FN:GID-276-EN.pdf

Form #GID-372-NT This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2015
Title: Life Plan Communities Disclosure Statement Checklist
Life Plan Communities Disclosure Statement Checklist. This form is to be filed as an accompanying document to the Disclosure Statement.
PID:1072-SID:2779-FN:GiD-372-NT.pdf

Form #GID-384-NT This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2015
Title: Life Plan Communities Annual Renewal Checksheet
Annual Statement
PID:1081-SID:3184-FN:GID-384-NT.pdf

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