This government document is issued by Human Services for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:yqjcmted-sw&q=https://www.dhs.pa.gov/docs/Documents/MA%2520Response%2520Forms/MA-376_Form-FINAL.pdf&sa=U&ved=2ahUKEwjqr6WC9PCFAxUw_7sIHXw_DG04HhAWegQIBhAB&usg=AOvVaw0L1Gil2shY-10DJp50y7gP&arm=e