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/service-provider-quicklinks/domiciliary-care-service-providers/Documents/Request%2520for%2520Regulatory%2520Waiver%2520Form%2520TEMPLATE.pdf&sa=U&ved=2ahUKEwj31-SU76_8AhXqTaQEHZ2JDiA4PBAWegQIAxAB&usg=AOvVaw1be8HbNo1TrHVddPd-w3Y1