1 Start 2 Complete Community Name, Account # and FAC Code * Allied Services Meade Street Residences, PA - 30602 FAC00765The Blake at Charlottesville, VA - 47201 FAC00566Bridgemoor Transitional Care of Ft. Worth, TX - 44502 FAC00511Bridgemoor Transitional Care of Round Rock, TX - 44501 FAC00500Bridgemoor Transitional Care of San Antonio, TX - 44503 FAC00531Bridgemoor Transitional Care of Webster, TX - 44504 FAC00567The Bridges at Warwick, PA - 34001 FAC00363Brookdale Highlands, FL - 43001 FAC00460Connecticut Baptist Homes Cedar Ridge, CT - 30506 FAC00553Daylesford Crossing, PA - 32003 FAC01056Echo Lake, PA - 32002 FAC00637Elmcroft of Lorain, OH - 37002 FAC00540The Enclave at Cedar Park, TX - 45003 FAC00561The Enclave at Round Rock, TX - 45002 FAC00560The Gardens of Green Ridge, PA - 28002 FAC00477Harmony at State College, PA - 49001 FAC00690The Heritage at Hunters Chase, TX - 44601 FAC00506The Highlands on the East Side, RI - 40036 FAC01593Kyffin Grove, PA - 32001 FAC00244Lake Travis Independent Living, TX - 45001 FAC00470The Landing of Towamencin, PA - 29202 – FAC01665The Legacy at South Plains, TX - 40301 FAC00465The Legacy at Town Square, TX - 40303 FAC00573Leighton Place, PA - 41001 FAC00413Plush Mills, PA - 35501 FAC00117Poet's Walk Cedar Park, TX - 32505 FAC00446Poet's Walk Henderson, NV - 32504 FAC00419Poet's Walk Leesburg, VA - 32507 FAC00499Poet's Walk Round Rock, TX - 32502 FAC00402Poet's Walk San Antonio, TX - 32503 FAC00410Poet's Walk Sarasota, FL - 32509 FAC00516Poet's Walk Warrenton, VA - 32508 FAC00503The Residence at Vinnin Square, MA - 40101 FAC00461The Ridglea Senior Living, TX - 29401 FAC00533Stone Hill at Andover, MA - 48001 FAC00570Sunrise of Blue Bell, PA - 25004 FAC00408Sunrise of Dresher, PA - 25001 FAC00084Sunrise of Exton, PA - 25006 FAC00475Sunrise of Granite Run, PA - 25014 FAC00524Sunrise of Haverford, PA - 25010 FAC00488Sunrise of Henderson, NV - 25008 FAC00481Sunrise of Lafayette Hill, PA - 25007 FAC00480Sunrise of Newtown Square, PA - 25011 FAC00489Sunrise of Paoli, PA - 25009 FAC00484Sunrise of Westtown, PA - 25013 FAC00497University Village Memory Care, TX - 28210 FAC01889Whitney Place, MA - 40401 FAC00485Willowbrook Place, PA - 41002 FAC00414Wingate Residences at Haverhill, MA - 42101 FAC00538Wyncote Place, PA - 41003 FAC00415 Employee Code * First Name * Last Name * Date of Service * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year202020212022 Resident First Name * Resident Last Name * Services * Matura Resident Account No. * Payment Type * AccountPOSGift Card Credit Card Authorization Code * Date of Credit Card Transaction * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Amount Charged * $ Add another Resident yes no Second Resident Resident First Name * Resident Last Name * Services * Matura Resident Account No. * Payment Type * AccountPOSGift Card Credit Card Authorization Code * Date of Credit Card Transaction * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Amount Charged * $ Add another Resident yes no Third Resident Resident First Name * Resident Last Name * Services * Matura Resident Account No. * Payment Type * AccountPOSGift Card Credit Card Authorization Code * Date of Credit Card Transaction * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Amount Charged * $ Add another Resident yes no Fourth Resident Resident First Name * Resident Last Name * Services * Matura Resident Account No. * Payment Type * AccountPOSGift Card Credit Card Authorization Code * Date of Credit Card Transaction * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Amount Charged * $ Add another Resident yes no Fifth Resident Resident First Name * Resident Last Name * Services * Matura Resident Account No. * Payment Type * AccountPOSGift Card Credit Card Authorization Code * Date of Credit Card Transaction * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Amount Charged * $ Add another Resident yes no Sixth Resident Resident First Name * Resident Last Name * Services * Matura Resident Account No. * Payment Type * AccountPOSGift Card Credit Card Authorization Code * Date of Credit Card Transaction * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Amount Charged * $ Add another Resident yes no Seventh Resident Resident First Name * Resident Last Name * Services * Matura Resident Account No. * Payment Type * AccountPOSGift Card Credit Card Authorization Code * Date of Credit Card Transaction * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Amount Charged * $ Add another Resident yes no Eighth Resident Resident First Name * Resident Last Name * Services * Matura Resident Account No. * Payment Type * AccountPOSGift Card Credit Card Authorization Code * Date of Credit Card Transaction * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Amount Charged * $ Add another Resident yes no Ninth Resident Resident First Name * Resident Last Name * Services * Matura Resident Account No. * Payment Type * AccountPOSGift Card Credit Card Authorization Code * Date of Credit Card Transaction * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Amount Charged * $ Add another Resident yes no Tenth Resident Resident First Name * Resident Last Name * Services * Matura Resident Account No. * Payment Type * AccountPOSGift Card Credit Card Authorization Code * Date of Credit Card Transaction * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Amount Charged * $ I agree that this information submitted is accurate and truthful. 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