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-electronic-forms/daas-0004_noticetoreportercompletionofevaluation_2-11-21.docx/@@download/file/DAAS-0004_NoticetoReporterCompletionofevaluation_2.11.21.docx