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%252025%2520%2520Domiciliary%2520Care/APD%252003-25-01%2520Revised%2520Domiciliary%2520Care%2520Agreement%2520Forms.pdf&sa=U&ved=2ahUKEwjqltSi5a_8AhVCXaQEHVnBCiAQFnoECAYQAg&usg=AOvVaw3Wc1Ze6HkYen4i0cttOQ9t