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/policy-procedure-manual/Documents/Appx%2520C.3%2520OPTIONS%2520Consumer%2520Reimbursement%2520Form_Other.pdf&sa=U&ved=2ahUKEwjK2dvk8K_8AhXpVKQEHa3FAiE4RhAWegQIBBAB&usg=AOvVaw2Rjw0KmW-J8TyrVa9-lUeX