This government document is issued by Commission on Crime & Delinquency for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:xjytqcyrvde&q=https://www.pccd.pa.gov/Victim-Services/Documents/DAVE/Stolen%2520Benefit%2520Cash%2520Claim%2520Form%25204-18-08.pdf&sa=U&ved=2ahUKEwjShOHO6emFAxVb9gIHHRmPDK44MhAWegQIARAB&usg=AOvVaw1fMrFD1A7PnQaFuubFse24