Florida Department of Elder Affairs Forms
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DOEA Form 235 "Affidavit of Compliance - Employer" - Florida
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71 votes
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DOEA/OPPG Form 002 "Professional Guardian Employee Registration Form" - Florida
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88 votes
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DOEA/SPGO Form 001 "Professional Guardian Registration Form" - Florida
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DOEA Form 236 "Affidavit of Compliance - Employee" - Florida
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DOEA Form ALF/ADRD-002 "Alzheimer's Disease and Related Disorders Training Three-Year Curriculum Certification" - Florida
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70 votes
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DOEA Form ALF/ADRD-001 "Alzheimer's Disease and Related Disorders Training Provider Certification" - Florida
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71 votes
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260 KB
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DOEA Form 234 "Application for Designation of a Home Health Agency as a Teaching Agency for Home and Community-Based Care" - Florida
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45 votes
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205 KB
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Form CCE-001 "Cce Impartial Decisionmaker Application" - Florida
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64 votes
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46 KB
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Form LTCOP-001 "Case Investigation - Confidential" - Florida
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51 votes
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Form ALFCT-002 "Application for Assisted Living Facility (Alf) Core Training Provider Registration" - Florida
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71 votes
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Form 001 "Professional Guardian Registration Form" - Florida
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81 votes
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DOEA Form HH/ADRD-001 "Application for Home Health Care Training Provider Certification - Alzheimer's Disease or Related Disorders Training" - Florida
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98 votes
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DOEA Form ADC/ADRD-001 "Application for Adult Day Care Training Provider Certification - Alzheimer's Disease or Related Disorders Training" - Florida
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DOEA Form Hospice/ADRD-001 "Application for Hospice Training Provider Certification - Alzheimer's Disease or Related Disorders Training" - Florida
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68 votes
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DOEA Form Hospice/ADRD-002 "Application for Hospice Three-Year Curriculum Certification - Alzheimer's Disease or Related Disorders Training" - Florida
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DOEA Form 183 "Request for Restriction on Use & Disclosure of Medical Information and/Or Confidential Communication" - Florida
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19 votes
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DOEA Form 187 "Revocation of Authorization to Release Protected Health Information (Phi)" - Florida
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DOEA Form 184 "Access to Records Request for Inspection of Protected Health Information (Phi)" - Florida
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DOEA Form 188 "Complaint Form" - Florida
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DOEA Form 190 "Hipaa Fax Cover Sheet" - Florida
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DOEA Form 185 "Amendment/Correction of Health Record Request Form" - Florida
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18 votes
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DOEA Form 181 "Employee Statement of Understanding of Privacy Policies" - Florida
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DOEA Form 189 "Client Disclosure Log" - Florida
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DOEA Form 182 "Authorization to Use or Disclose Health Information" - Florida
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DOEA Form 186 "Request for Accounting of Disclosures of Protected Health Information" - Florida
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63 votes
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DOEA Form ADRD-001 "Application for Nursing Home Training Provider Certification - Alzheimer's Disease or Related Disorders Training" - Florida
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47 votes
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255 KB
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Instructions for DOEA Form 154 Attachment 4 "Eligibility Financial Worksheet and Assessed Co-payment Form" - Florida, 2018
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11 votes
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Form 701A "Condensed Assessment" - Florida
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95 votes
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450 KB
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Form 701C "Congregate Meals Assessment" - Florida
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41 votes
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DOEA Form 701B "Comprehensive Assessment" - Florida
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55 votes
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"Formulario CACFP De Admisibilidad Para Beneficios Alimentarios Conforme a Los Ingresos (Cuidado De Adultos)" - Florida (Spanish)
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30 votes
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165 KB
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"CACFP Meal Benefit Income Eligibility Form (Adult Care)" - Florida
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19 votes
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"Hoja De Gastos Mensuales" - Florida (Spanish)
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24 votes
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"Cambio De Informacion" - Florida (Spanish)
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"Lista De Inscripcion Del Acfp" - Florida (Spanish)
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"Annual Information Certification Form - Adult Care Food Program (Acfp)" - Florida
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68 votes
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79 KB
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"Public News Release for Non-pricing Programs" - Florida
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42 votes
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"Food Service Management Contract" - Florida
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49 votes
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"Catering Information Form - Adult Care Food Program (Acfp)" - Florida
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60 votes
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"CACFP Meal Benefit Income Eligibility Form - Adult Care Food Program (Acfp)" - Florida
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![DOEA Form 235 "Affidavit of Compliance - Employer" - Florida](https://data.templateroller.com/pdf_docs_html/1783/17837/1783747/form-235-affidavit-compliance-employer-florida.png "DOEA Form 235 "Affidavit of Compliance - Employer" - Florida")
![DOEA/OPPG Form 002 "Professional Guardian Employee Registration Form" - Florida](https://data.templateroller.com/pdf_docs_html/1783/17838/1783819/doea-oppg-form-002-professional-guardian-employee-registration-form-florida.png "DOEA/OPPG Form 002 "Professional Guardian Employee Registration Form" - Florida")
![DOEA/SPGO Form 001 "Professional Guardian Registration Form" - Florida](https://data.templateroller.com/pdf_docs_html/1783/17838/1783820/doea-spgo-form-001-professional-guardian-registration-form-florida.png "DOEA/SPGO Form 001 "Professional Guardian Registration Form" - Florida")
![DOEA Form 236 "Affidavit of Compliance - Employee" - Florida](https://data.templateroller.com/pdf_docs_html/1783/17837/1783752/form-236-affidavit-compliance-employee-florida.png "DOEA Form 236 "Affidavit of Compliance - Employee" - Florida")
![DOEA Form ALF/ADRD-002 "Alzheimer's Disease and Related Disorders Training Three-Year Curriculum Certification" - Florida](https://data.templateroller.com/pdf_docs_html/1783/17837/1783734/form-alf-adrd-002-alzheimer-s-disease-and-related-disorders-training-three-year-curriculum-certification-florida.png "DOEA Form ALF/ADRD-002 "Alzheimer's Disease and Related Disorders Training Three-Year Curriculum Certification" - Florida")
![DOEA Form ALF/ADRD-001 "Alzheimer's Disease and Related Disorders Training Provider Certification" - Florida](https://data.templateroller.com/pdf_docs_html/1783/17837/1783737/form-alf-adrd-001-alzheimer-s-disease-and-related-disorders-training-provider-certification-florida.png "DOEA Form ALF/ADRD-001 "Alzheimer's Disease and Related Disorders Training Provider Certification" - Florida")
![DOEA Form 234 "Application for Designation of a Home Health Agency as a Teaching Agency for Home and Community-Based Care" - Florida](https://data.templateroller.com/pdf_docs_html/1783/17837/1783795/form-234-application-designation-a-home-health-agency-as-a-teaching-agency-home-and-community-based-care-florida.png "DOEA Form 234 "Application for Designation of a Home Health Agency as a Teaching Agency for Home and Community-Based Care" - Florida")
![Form CCE-001 "Cce Impartial Decisionmaker Application" - Florida](https://data.templateroller.com/pdf_docs_html/1765/17658/1765884/form-cce-001-cce-impartial-decisionmaker-application-florida.png "Form CCE-001 "Cce Impartial Decisionmaker Application" - Florida")
![Form LTCOP-001 "Case Investigation - Confidential" - Florida](https://data.templateroller.com/pdf_docs_html/1765/17658/1765882/form-ltcop-001-case-investigation-confidential-florida.png "Form LTCOP-001 "Case Investigation - Confidential" - Florida")
![Form ALFCT-002 "Application for Assisted Living Facility (Alf) Core Training Provider Registration" - Florida](https://data.templateroller.com/pdf_docs_html/1765/17658/1765890/form-alfct-002-application-assisted-living-facility-alf-core-training-provider-registration-florida.png "Form ALFCT-002 "Application for Assisted Living Facility (Alf) Core Training Provider Registration" - Florida")
![Form 001 "Professional Guardian Registration Form" - Florida](https://data.templateroller.com/pdf_docs_html/1765/17658/1765886/form-001-professional-guardian-registration-form-florida.png "Form 001 "Professional Guardian Registration Form" - Florida")
![DOEA Form HH/ADRD-001 "Application for Home Health Care Training Provider Certification - Alzheimer's Disease or Related Disorders Training" - Florida](https://data.templateroller.com/pdf_docs_html/1783/17837/1783738/form-hh-adrd-001-application-home-health-care-training-provider-certification-alzheimer-s-disease-or-related-disorders-training-florida.png "DOEA Form HH/ADRD-001 "Application for Home Health Care Training Provider Certification - Alzheimer's Disease or Related Disorders Training" - Florida")
![DOEA Form ADC/ADRD-001 "Application for Adult Day Care Training Provider Certification - Alzheimer's Disease or Related Disorders Training" - Florida](https://data.templateroller.com/pdf_docs_html/1783/17837/1783735/form-adc-adrd-001-application-adult-day-care-training-provider-certification-alzheimer-s-disease-or-related-disorders-training-florida.png "DOEA Form ADC/ADRD-001 "Application for Adult Day Care Training Provider Certification - Alzheimer's Disease or Related Disorders Training" - Florida")
![DOEA Form Hospice/ADRD-001 "Application for Hospice Training Provider Certification - Alzheimer's Disease or Related Disorders Training" - Florida](https://data.templateroller.com/pdf_docs_html/1783/17837/1783739/form-hospice-adrd-001-application-hospice-training-provider-certification-alzheimer-s-disease-or-related-disorders-training-florida.png "DOEA Form Hospice/ADRD-001 "Application for Hospice Training Provider Certification - Alzheimer's Disease or Related Disorders Training" - Florida")
![DOEA Form Hospice/ADRD-002 "Application for Hospice Three-Year Curriculum Certification - Alzheimer's Disease or Related Disorders Training" - Florida](https://data.templateroller.com/pdf_docs_html/1783/17837/1783740/form-hospice-adrd-002-application-hospice-three-year-curriculum-certification-alzheimer-s-disease-or-related-disorders-training-florida.png "DOEA Form Hospice/ADRD-002 "Application for Hospice Three-Year Curriculum Certification - Alzheimer's Disease or Related Disorders Training" - Florida")
![DOEA Form 183 "Request for Restriction on Use & Disclosure of Medical Information and/Or Confidential Communication" - Florida](https://data.templateroller.com/pdf_docs_html/1763/17638/1763897/doea-form-183-request-for-restriction-on-use-disclosure-of-medical-information-and-or-confidential-communication-florida.png "DOEA Form 183 "Request for Restriction on Use & Disclosure of Medical Information and/Or Confidential Communication" - Florida")
![DOEA Form 187 "Revocation of Authorization to Release Protected Health Information (Phi)" - Florida](https://data.templateroller.com/pdf_docs_html/1763/17639/1763901/doea-form-187-revocation-of-authorization-to-release-protected-health-information-phi-florida.png "DOEA Form 187 "Revocation of Authorization to Release Protected Health Information (Phi)" - Florida")
![DOEA Form 184 "Access to Records Request for Inspection of Protected Health Information (Phi)" - Florida](https://data.templateroller.com/pdf_docs_html/1763/17638/1763898/doea-form-184-access-to-records-request-for-inspection-of-protected-health-information-phi-florida.png "DOEA Form 184 "Access to Records Request for Inspection of Protected Health Information (Phi)" - Florida")
![DOEA Form 188 "Complaint Form" - Florida](https://data.templateroller.com/pdf_docs_html/1763/17639/1763902/doea-form-188-complaint-form-florida.png "DOEA Form 188 "Complaint Form" - Florida")
![DOEA Form 190 "Hipaa Fax Cover Sheet" - Florida](https://data.templateroller.com/pdf_docs_html/1763/17639/1763904/doea-form-190-hipaa-fax-cover-sheet-florida.png "DOEA Form 190 "Hipaa Fax Cover Sheet" - Florida")
![DOEA Form 185 "Amendment/Correction of Health Record Request Form" - Florida](https://data.templateroller.com/pdf_docs_html/1763/17638/1763899/doea-form-185-amendment-correction-of-health-record-request-form-florida.png "DOEA Form 185 "Amendment/Correction of Health Record Request Form" - Florida")
![DOEA Form 181 "Employee Statement of Understanding of Privacy Policies" - Florida](https://data.templateroller.com/pdf_docs_html/1763/17638/1763895/doea-form-181-employee-statement-of-understanding-of-privacy-policies-florida.png "DOEA Form 181 "Employee Statement of Understanding of Privacy Policies" - Florida")
![DOEA Form 189 "Client Disclosure Log" - Florida](https://data.templateroller.com/pdf_docs_html/1763/17639/1763903/doea-form-189-client-disclosure-log-florida.png "DOEA Form 189 "Client Disclosure Log" - Florida")
![DOEA Form 182 "Authorization to Use or Disclose Health Information" - Florida](https://data.templateroller.com/pdf_docs_html/1763/17638/1763896/doea-form-182-authorization-to-use-or-disclose-health-information-florida.png "DOEA Form 182 "Authorization to Use or Disclose Health Information" - Florida")
![DOEA Form 186 "Request for Accounting of Disclosures of Protected Health Information" - Florida](https://data.templateroller.com/pdf_docs_html/1763/17639/1763900/doea-form-186-request-for-accounting-of-disclosures-of-protected-health-information-florida.png "DOEA Form 186 "Request for Accounting of Disclosures of Protected Health Information" - Florida")
![DOEA Form ADRD-001 "Application for Nursing Home Training Provider Certification - Alzheimer's Disease or Related Disorders Training" - Florida](https://data.templateroller.com/pdf_docs_html/1783/17837/1783742/form-adrd-001-application-nursing-home-training-provider-certification-alzheimer-s-disease-or-related-disorders-training-florida.png "DOEA Form ADRD-001 "Application for Nursing Home Training Provider Certification - Alzheimer's Disease or Related Disorders Training" - Florida")
![Instructions for DOEA Form 154 Attachment 4 "Eligibility Financial Worksheet and Assessed Co-payment Form" - Florida, 2018](https://data.templateroller.com/pdf_docs_html/1783/17837/1783789/attachment-4-instructions-doea-form-154-eligibility-financial-worksheet-and-assessed-co-payment-form-2018.png "Instructions for DOEA Form 154 Attachment 4 "Eligibility Financial Worksheet and Assessed Co-payment Form" - Florida, 2018")
![Form 701A "Condensed Assessment" - Florida](https://data.templateroller.com/pdf_docs_html/1765/17656/1765687/form-701a-condensed-assessment-florida.png "Form 701A "Condensed Assessment" - Florida")
![Form 701C "Congregate Meals Assessment" - Florida](https://data.templateroller.com/pdf_docs_html/1765/17656/1765688/form-701c-congregate-meals-assessment-florida.png "Form 701C "Congregate Meals Assessment" - Florida")
![DOEA Form 701B "Comprehensive Assessment" - Florida](https://data.templateroller.com/pdf_docs_html/1783/17837/1783772/form-701b-comprehensive-assessment-florida.png "DOEA Form 701B "Comprehensive Assessment" - Florida")
!["Formulario CACFP De Admisibilidad Para Beneficios Alimentarios Conforme a Los Ingresos (Cuidado De Adultos)" - Florida (Spanish)](https://data.templateroller.com/pdf_docs_html/2021/20218/2021885/formulario-cacfp-de-admisibilidad-para-beneficios-alimentarios-conforme-a-los-ingresos-cuidado-de-adultos-florida-spanish.png ""Formulario CACFP De Admisibilidad Para Beneficios Alimentarios Conforme a Los Ingresos (Cuidado De Adultos)" - Florida (Spanish)")
!["CACFP Meal Benefit Income Eligibility Form (Adult Care)" - Florida](https://data.templateroller.com/pdf_docs_html/2021/20218/2021888/cacfp-meal-benefit-income-eligibility-form-adult-care-florida.png ""CACFP Meal Benefit Income Eligibility Form (Adult Care)" - Florida")
!["Hoja De Gastos Mensuales" - Florida (Spanish)](https://data.templateroller.com/pdf_docs_html/2021/20218/2021887/hoja-de-gastos-mensuales-florida-spanish.png ""Hoja De Gastos Mensuales" - Florida (Spanish)")
!["Cambio De Informacion" - Florida (Spanish)](https://data.templateroller.com/pdf_docs_html/2021/20218/2021883/cambio-de-informacion-florida-spanish.png ""Cambio De Informacion" - Florida (Spanish)")
!["Lista De Inscripcion Del Acfp" - Florida (Spanish)](https://data.templateroller.com/pdf_docs_html/2021/20218/2021884/lista-de-inscripcion-del-acfp-florida-spanish.png ""Lista De Inscripcion Del Acfp" - Florida (Spanish)")
!["Annual Information Certification Form - Adult Care Food Program (Acfp)" - Florida](https://data.templateroller.com/pdf_docs_html/1783/17838/1783850/annual-information-certification-form-adult-care-food-program-acfp-florida.png ""Annual Information Certification Form - Adult Care Food Program (Acfp)" - Florida")
!["Public News Release for Non-pricing Programs" - Florida](https://data.templateroller.com/pdf_docs_html/1783/17838/1783852/public-news-release-non-pricing-programs-florida.png ""Public News Release for Non-pricing Programs" - Florida")
!["Food Service Management Contract" - Florida](https://data.templateroller.com/pdf_docs_html/1783/17838/1783866/food-service-management-contract-florida.png ""Food Service Management Contract" - Florida")
!["Catering Information Form - Adult Care Food Program (Acfp)" - Florida](https://data.templateroller.com/pdf_docs_html/1783/17838/1783858/catering-information-form-adult-care-food-program-acfp-florida.png ""Catering Information Form - Adult Care Food Program (Acfp)" - Florida")
!["CACFP Meal Benefit Income Eligibility Form - Adult Care Food Program (Acfp)" - Florida](https://data.templateroller.com/pdf_docs_html/1783/17838/1783840/cacfp-meal-benefit-income-eligibility-form-adult-care-food-program-acfp-florida.png ""CACFP Meal Benefit Income Eligibility Form - Adult Care Food Program (Acfp)" - Florida")
