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Section A: Owner/Filer Information Owner Name: Business Name: Mailing Address: Contact E-Mail Address: Section B: Property Information Franchise Name Property Address: Gross Sq Ft: Parcel(s): Section C: Reporting Info 1. Bed Count For 2025: Total # of Beds: Potential Patient Days: Actual Patient Days: For 2024: Total # of Beds: Potential Patient Days: Actual Patient Days: For 2023: Total # of Beds: Potential Patient Days: Actual Patient Days: 2. Facility Type Skilled Nursing: % Memory Care: % Assisted Living: % Independent Living: % Other % 3. Overall Occupancy Rate (2025) Medicare Part A: % Medicaid: % Private & Other: % Managed Care: % Assisted Living: % 4. Amenities Offered: (Yes/No) Dining Room: Library: Physical Therapy: Activity Room Other: 5. Furnished Rooms: Number Provided: 6. Units unable to be occupied: Number: Reason: 5. Please submit your last three years (2023, 2024, & 2025) Income & Expense information to complete this filing. Contact Person: Management Firm (if applicable) Address: Phone: Signature: Title: Date: All information including the accompanying schedules and statements have been examined by me and to the best of my knowledge and belief are true, correct, and complete. Per IC 6-1.1-35-9, any information pertaining to income expense is constitutionally protected and will remain confidential. Allen County Assessor - Stacey O'Day Rousseau Centre, 1 E Main Street Suite 415 Fort Wayne IN 46802 Ph [PHONE REDACTED] Fax [PHONE REDACTED] Allen Survey Facility Medical Residential County