This government document is issued by Drug and Alcohol Programs for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:ug3qpcrqbm4&q=https://www.ddap.pa.gov/Documents/Agency%2520Forms/Fiscal/Drug%2520and%2520Alcohol%2520Client%2520Liability%2520Determination%2520Form.xlsx&sa=U&ved=2ahUKEwjhz9bhlPGFAxUxiP0HHRGND6oQFnoECAcQAQ&usg=AOvVaw2SWAmapnM-wTAzcKg8T2MY