This government document is issued by Division of Aging and Adult Services for use in North Carolina
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https://policies.ncdhhs.gov/divisional/aging-and-adult/adult-protective-services/forms/adult-protective-services-handwritten-forms/daas-0013_determinationofabilitytoconsentform_hw_2-11-21.docx/@@download/file/DAAS-0013_DeterminationofAbilitytoConsentForm_HW_2.11.21.docx