Information & Guide Request

Information & Guide Request Letter from the Publisher Tell us a bit more about your needs so we may offer the best resources to help you . Please complete only the amount of information you feel comfortable sharing . We will follow up with you by phone or email (whichever you prefer) . When you’ve completed the form, please cut out this page, place in a stamped envelope and mail to: Attn: Help & Information Retirement Connection Guide PO Box 820067 Portland, OR 97282 You may also fax the form to: 503-334-2868 Or you may contact us online at: www .RetirementConnection .com

name

e-mail address:

address: day phone number:

city, state, zip:

Inquiring for: self friend relative If other than you, what is the name and age of person needing assistance: first name: age:

Desired location for the housing, service(s) or product(s) to be provided:

I would like extra copies of the guide sent to me . Puget Sound Portland/Vancouver Mid-Willamette Valley Southern Oregon

I would like more information about:

Care & Health Services

Adult Day Programs Ambulatory Aids Care Management Emergency Response Systems Health Insurance/Medicare Home Health/In Home Care Hospice Medical Equipment/Supply Prescription Assistance Rehabilitation/Therapy Respite Care Other

Housing

Assisted Living/ Residential Care Independent Living

Preferred Location Memory Care Nursing Home

Professional Services

Elder Law/Estate Planning Financial Planning Long-Term Care Insurance Moving/Real Estate Services Reverse Mortgages Other

Additional Information

When do you expect to need housing, service(s) or product(s)? Now Within 6 months 6 to 12 months Later What type of funding will you use to pay for services? Private Pay Medicare Long-Term Care Insurance Medicaid or Public Assistance Health Insurance Veteran Benefits