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/Eligibility%2520Determination%2520Form.pdf&sa=U&ved=2ahUKEwjqr6WC9PCFAxUw_7sIHXw_DG04HhAWegQIBxAB&usg=AOvVaw3_zUbIOsDgZlOlPNHinQz2&arm=e