The image shows a document with printed text and handwritten notes. The document appears to be an official form or letterhead due to the presence of a header that includes numbers such as "A52" followed by a date range and other information, which could suggest it's from a legal or administrative context. There are checkboxes and lines for writing in response to certain questions or prompts. The handwriting is in black ink and seems to be responding to the printed items on the form.