This government document is issued by Developmental Disabilities Council for use in West Virginia
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https://www.google.com/url?client=internal-element-cse&cx=007317577438028001491:qxdark6-xew&q=https://ddc.wv.gov/council-projects/grantfunding/Documents/Draft%2520Waiver%2520Forms%2520Comments%2520June%25202011.pdf&sa=U&ved=2ahUKEwiKy9nDnISNAxW_hP0HHfrpNh8QFnoECAUQAQ&usg=AOvVaw3tioVRLbQi_-F6yaK7ElxE