This government document is issued by Department of Aging for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:p5rt2izphxk&q=https://www.aging.pa.gov/Documents/2017%2520DCW%2520of%2520Year%2520Nomination%2520Form%2520V2pdf.pdf&sa=U&ved=2ahUKEwjqltSi5a_8AhVCXaQEHVnBCiAQFnoECAMQAQ&usg=AOvVaw3MnTF90ArhnSVnAYDsG4BP