This government document is issued by Department of Aging for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:p5rt2izphxk&q=https://www.aging.pa.gov/publications/aging-program-directives/Program%2520Area%252005%2520%2520Employment/APD%252007-05-01%2520Elig%2520Determination%2520IEP%2520Forms.pdf&sa=U&ved=2ahUKEwio-ais5q_8AhW_UKQEHZpLAh84ChAWegQIABAC&usg=AOvVaw1b3um825s6ySihPucz77Kg