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/organization/pa-council-on-aging/pcoa-doc-repository/Documents/PCOA%2520Expense%2520Form%2520Updated%25209-6-19_.pdf&sa=U&ved=2ahUKEwioiZnw9K_8AhURRsAKHbuwAWQ4WhAWegQICRAB&usg=AOvVaw1PK5aDXmXsS6rvezDEdmZ1