This government document is issued by Oregon Temporary Assistance for Needy Families for use in Oregon
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https://www.google.com/url?client=internal-element-cse&cx=014529913148261890260:fute8kcjwgo&q=https://www.oregon.gov/dhs/SENIORS-DISABILITIES/LTC/Documents/APD-2803.pdf&sa=U&ved=2ahUKEwj9iKaU_rn9AhUHZsAKHUuUAv04ChAWegQIABAC&usg=AOvVaw0_iyCbMvG6dqxvlpcQXumI