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//The following adds the values and stores them in the Gravity form in hidden fields(119, 123, 122, etc.)	
	/* A + B */
					listFieldColumnTotal( 1, 30, 2, 119, true );
					listFieldColumnTotal( 1, 120, 2, 123, true );
					listFieldColumnTotal( 1, 121, 2, 122, true );
	/*User snap + other */
					listFieldColumnTotal( 1, 153, 2, 137, true );
					listFieldColumnTotal( 1, 134, 2, 136, true );
	/*Spouse snap + other */
					listFieldColumnTotal( 1, 155, 2, 133, true );
					listFieldColumnTotal( 1, 130, 2, 132, true );
	/*Household snap + other */
					listFieldColumnTotal( 1, 125, 2, 129, true );
					listFieldColumnTotal( 1, 127, 2, 128, true );
	/* mpap */
					listFieldColumnTotal( 1, 135, 2, 154, true );
					listFieldColumnTotal( 1, 131, 2, 156, true );
				
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			</script>

			

			<script type="text/javascript">

				jQuery(document).ready(function(){

					function calculateLFColumnTotal(formId, columnClass, totalFieldId, currency) {
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//The following adds the values and stores them in the Gravity form in hidden fields(119, 123, 122, etc.)	
	/* A + B */
					listFieldColumnTotal( 1, 30, 2, 119, true );
					listFieldColumnTotal( 1, 120, 2, 123, true );
					listFieldColumnTotal( 1, 121, 2, 122, true );
	/*User snap + other */
					listFieldColumnTotal( 1, 153, 2, 137, true );
					listFieldColumnTotal( 1, 134, 2, 136, true );
	/*Spouse snap + other */
					listFieldColumnTotal( 1, 155, 2, 133, true );
					listFieldColumnTotal( 1, 130, 2, 132, true );
	/*Household snap + other */
					listFieldColumnTotal( 1, 125, 2, 129, true );
					listFieldColumnTotal( 1, 127, 2, 128, true );
	/* mpap */
					listFieldColumnTotal( 1, 135, 2, 154, true );
					listFieldColumnTotal( 1, 131, 2, 156, true );
				
				});	

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			{"id":5734,"date":"2024-06-07T12:59:39","date_gmt":"2024-06-07T16:59:39","guid":{"rendered":"https:\/\/benefits.proseniors.org\/?page_id=5734"},"modified":"2024-06-07T13:01:38","modified_gmt":"2024-06-07T17:01:38","slug":"5734-2","status":"publish","type":"page","link":"https:\/\/benefits.proseniors.org\/?page_id=5734","title":{"rendered":"Interview"},"content":{"rendered":"\r\n\r\n\r\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">SNAP Application<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F5734#gf_1' data-formid='1' novalidate>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>11<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_9' style='width:9%;'><span>9%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_181\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_181\" >This interview will help Ohio residents determine whether they are eligible for certain public benefits and the amount of benefits for which they may qualify. \n\nThis interview will determine eligibility for the Medicare Premium Assistance Program, Expanded Medicaid, and Extra Help with Part-D.  The interview will also determine eligibility for the Supplemental Nutrition Assistance Program and provide an estimated monthly benefit.\n\nDuring this interview, touch or hover over the grey question mark to get additional information about the question.\n<\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_179' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_1_2_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-179' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_188\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_188\" >This interview will take approximately 20-30 minutes.  You may pause the interview and return to the interview at any time by hitting the \u201cSave and Continue Later\u201d button.  At that time a link will be provided that you can use to return to the interview.  <\/div><fieldset id=\"field_1_189\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_189\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please confirm the following statements by checking the boxes:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_189'><div class='gchoice gchoice_1_189_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_189.1' type='checkbox'  value='I live in Ohio or I am completing this interview on behalf of someone who does live in Ohio;'  id='choice_1_189_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_189_1' id='label_1_189_1' class='gform-field-label gform-field-label--type-inline'>I live in Ohio or I am completing this interview on behalf of someone who does live in Ohio;<\/label>\n\t\t\t\t\t\t\t<\/div><html><body><div class=\"gchoice gchoice_1_189_2 has-tooltip\">\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_189.2\" type=\"checkbox\" value=\"I am a United States citizen;\" id=\"choice_1_189_2\" aria-describedby=\"gftt-1_189_2-wrap\">\n\t\t\t\t\t\t\t\t<label for=\"choice_1_189_2\" id=\"label_1_189_2\" class=\"gform-field-label gform-field-label--type-inline\"><gftt-label class=\"gftt-label\">I am a United States citizen;<\/gftt-label><i class=\"gftt-icon gform-theme__no-reset--el\" id=\"gftt-1_189_2\" data-placement=\"se\" tabindex=\"0\"><\/i><div id=\"gftt-1_189_2-wrap\" class=\"gftt-content\" aria-hidden=\"false\" role=\"tooltip\"><div aria-hidden=\"false\" id=\"gftt-1_189_2-content\" data-tid=\"gftt-1_189_2\">People who are not U.S. Citizens may be eligible based on specific criteria and rules.  These situations are not covered by this interview.<\/div><\/div><\/label>\n\t\t\t\t\t\t\t<\/div><\/body><\/html><div class='gchoice gchoice_1_189_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_189.3' type='checkbox'  value='I understand this interview is not intended as legal advice;'  id='choice_1_189_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_189_3' id='label_1_189_3' class='gform-field-label gform-field-label--type-inline'>I understand this interview is not intended as legal advice;<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_189_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_189.4' type='checkbox'  value='I understand this interview is not a substitute for consulting an attorney;'  id='choice_1_189_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_189_4' id='label_1_189_4' class='gform-field-label gform-field-label--type-inline'>I understand this interview is not a substitute for consulting an attorney;<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_189_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_189.5' type='checkbox'  value='I understand this interview does not establish an attorney-client relationship.'  id='choice_1_189_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_189_5' id='label_1_189_5' class='gform-field-label gform-field-label--type-inline'>I understand this interview does not establish an attorney-client relationship.<\/label>\n\t\t\t\t\t\t\t<\/div><button type=\"button\" id=\"button_189_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"Select All\" data-label-deselect=\"Deselect All\">Select All<\/button><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_180' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_180' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_1_3_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-180' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_158\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_158\" >Please provide your contact information.  We will send your answers to the email address you provide.  Your email address will not be used for any other solicitations.  \n<\/div><div id=\"field_1_2\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_2\" ><label class='gfield_label gform-field-label' for='input_1_2'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_1_2' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\" ><label class='gfield_label gform-field-label' for='input_1_10'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_143\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_143\" ><html><body><label class=\"gfield_label gform-field-label\" for=\"input_1_143\"><gftt-label class=\"gftt-label\">Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/gftt-label><i id=\"gftt-1_143\" class=\"gftt-icon gform-theme__no-reset--el\" tabindex=\"0\" data-placement=\"se\"><\/i><div class=\"gftt-content\" id=\"gftt-1_143-wrap\" role=\"tooltip\" aria-hidden=\"false\"><div id=\"gftt-1_143-content\" data-tid=\"gftt-1_143\" aria-hidden=\"false\">Email is required to save progress and provide details at the completion of this questionnaire.<\/div><\/div><\/label><div class=\"ginput_container ginput_container_email\">\n                            <input name=\"input_143\" id=\"input_1_143\" type=\"email\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gftt-1_143-wrap\">\n                        <\/div><\/body><\/html><\/div><div id=\"field_1_144\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_144\" ><label class='gfield_label gform-field-label' for='input_1_144'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_144' id='input_1_144' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\" ><html><body><label class=\"gfield_label gform-field-label\" for=\"input_1_11\"><gftt-label class=\"gftt-label\">Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/gftt-label><i id=\"gftt-1_11\" class=\"gftt-icon gform-theme__no-reset--el\" tabindex=\"0\" data-placement=\"se\"><\/i><div class=\"gftt-content\" id=\"gftt-1_11-wrap\" role=\"tooltip\" aria-hidden=\"false\"><div id=\"gftt-1_11-content\" data-tid=\"gftt-1_11\" aria-hidden=\"false\">Age is required because SNAP benefits are dependent on an applicant's age.<\/div><\/div><\/label><div class=\"ginput_container ginput_container_number\"><input name=\"input_11\" id=\"input_1_11\" type=\"number\" step=\"any\" value=\"\" class=\"large\" aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gftt-1_11-wrap\"><\/div><div class=\"gfield_description\" id=\"gfield_description_1_11\">Benefit calculations are based on the age of household members.\n<\/div><\/body><\/html><\/div><fieldset id=\"field_1_145\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_145\" ><html><body><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\"><\/i><span>Hidden<\/span><\/div><legend class=\"gfield_label gform-field-label\"><gftt-label class=\"gftt-label\">Is it okay for Pro Seniors to contact you about your interview questions?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/gftt-label><i id=\"gftt-1_145\" class=\"gftt-icon gform-theme__no-reset--el\" tabindex=\"0\" data-placement=\"se\"><\/i><div class=\"gftt-content\" id=\"gftt-1_145-wrap\" role=\"tooltip\" aria-hidden=\"false\"><div id=\"gftt-1_145-content\" data-tid=\"gftt-1_145\" aria-hidden=\"false\">If you answer \"Yes\", Pro Seniors may be able to assist you in applying for benefits or answer additional questions.  Availability to follow-up is dependent on whether Pro Seniors has help from student interns or other volunteers.<\/div><\/div><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_1_145\">\n\t\t\t<div class=\"gchoice gchoice_1_145_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_145\" type=\"radio\" value=\"Yes\" id=\"choice_1_145_0\" onchange=\"gformToggleRadioOther( this )\" aria-describedby=\"gftt-1_145-wrap\">\n\t\t\t\t\t<label for=\"choice_1_145_0\" id=\"label_1_145_0\" class=\"gform-field-label gform-field-label--type-inline\">Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_1_145_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_145\" type=\"radio\" value=\"No\" id=\"choice_1_145_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_1_145_1\" id=\"label_1_145_1\" class=\"gform-field-label gform-field-label--type-inline\">No<\/label>\n\t\t\t<\/div><\/div><\/div><div class=\"gfield_description\" id=\"gfield_description_1_145\">If you answer \"Yes\", Pro Seniors may be able to assist you in applying for benefits or answer additional questions about your benefits.  \n<\/div><\/body><\/html><\/fieldset><fieldset id=\"field_1_159\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_159\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Contact Me By:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_159'><div class='gchoice gchoice_1_159_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.1' type='checkbox'  value='Phone Call 9AM - Noon'  id='choice_1_159_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_159_1' id='label_1_159_1' class='gform-field-label gform-field-label--type-inline'>Phone Call 9AM - Noon<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_159_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.2' type='checkbox'  value='Phone Call Noon - 3PM'  id='choice_1_159_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_159_2' id='label_1_159_2' class='gform-field-label gform-field-label--type-inline'>Phone Call Noon - 3PM<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_159_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.3' type='checkbox'  value='Phone Call 3PM - 5PM'  id='choice_1_159_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_159_3' id='label_1_159_3' class='gform-field-label gform-field-label--type-inline'>Phone Call 3PM - 5PM<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_159_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.4' type='checkbox'  value='Email'  id='choice_1_159_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_159_4' id='label_1_159_4' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_1' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_1' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_1_4_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-1' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_194\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_194\" >Marital information is crucial in determining eligibility of benefit programs.  Married individuals are assumed to share income and resources.  \n\nDisability status is required for the proper calculation of SNAP benefits.  Households with a disabled individual may determine eligibility or increase monthly benefits.<\/div><div id=\"field_1_13\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\" ><html><body><label class=\"gfield_label gform-field-label\" for=\"input_1_13\"><gftt-label class=\"gftt-label\">Marital Status<\/gftt-label><i id=\"gftt-1_13\" class=\"gftt-icon gform-theme__no-reset--el\" tabindex=\"0\" data-placement=\"se\"><\/i><div class=\"gftt-content\" id=\"gftt-1_13-wrap\" role=\"tooltip\" aria-hidden=\"false\"><div id=\"gftt-1_13-content\" data-tid=\"gftt-1_13\" aria-hidden=\"false\">If you are married and living with your spouse, most benefit programs count the income and resources of both you and your spouse when determining eligibility. You and your spouse are living together, if both of you live in the same household. The income and resources of both you and your spouse are counted, regardless of whether one or both of you are filing for benefits. You are still considered to be living together, if you or your spouse are temporarily absent from the household due to treatment in a hospital or nursing home.<\/div><\/div><\/label><div class=\"ginput_container ginput_container_select\"><select name=\"input_13\" id=\"input_1_13\" class=\"large gfield_select\" aria-invalid=\"false\"><option value=\"Married &amp; Living Together\">Married &amp; Living Together<\/option><option value=\"Married &amp; Not Living Together\">Married &amp; Not Living Together<\/option><option value=\"Single\">Single<\/option><option value=\"Divorced\">Divorced<\/option><option value=\"Widowed\">Widowed<\/option><option value=\"Separated - Temporarily\">Separated - Temporarily<\/option><\/select><\/div><\/body><\/html><\/div><div id=\"field_1_203\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_203\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_203'>Married?<\/label><div class='ginput_container ginput_container_text'><input name='input_203' id='input_1_203' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_203\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_1_203'>hidden field to report married formula<\/div><\/div><div id=\"field_1_15\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_15\" ><label class='gfield_label gform-field-label' for='input_1_15'>Do you receive Social Security Disability, or does someone in your household receive Social Security Disability<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_15' id='input_1_15' class='large gfield_select'  aria-describedby=\"gfield_description_1_15\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='true' >I receive Social Security Disability<\/option><option value='true' >I provide care to a household member who receives Social Security Disabilityanother disabled household member<\/option><option value='true' >I receive and I care for another household member who receives Social Security Disability<\/option><option value='false' >I do not receive, nor do I care for someone who receives Social Security Disability<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_15'>\n<\/div><\/div><div id=\"field_1_16\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_16\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_16'>Are you, and members of your household, Unitd States Citizens?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_1_16' class='large gfield_select'  aria-describedby=\"gfield_description_1_16\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_16'>\n<\/div><\/div><div id=\"field_1_18\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_18\" ><p>Each program has specific rules and requirements for non-citizens.  This interview is unable to provide you accurate information for resident-aliens. <\/p><p> If you are over 60, please call our Helpline for further guidance. 513-345-4160.<\/p><\/div><fieldset id=\"field_1_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_21\" ><legend class='gfield_label gform-field-label' >Do you receive Medicare?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_21'>\n\t\t\t<div class='gchoice gchoice_1_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='true'  id='choice_1_21_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_21\"   \/>\n\t\t\t\t\t<label for='choice_1_21_0' id='label_1_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='false'  id='choice_1_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_21_1' id='label_1_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_21'>Medicare is a federal health insurance that is available to people over 65 or people who have been deemed disabled for 2 or more years. \n<\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_195' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_195' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_1_5_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_5' class='gform_page' data-js='page-field-id-195' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_196\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_196\" >Please provide information regarding your spouse. Information is required for SNAP, Medicare Premium Assistance Programs, and Extra Help with Prescription Costs.<\/div><div id=\"field_1_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\" ><label class='gfield_label gform-field-label' for='input_1_26'>Spouse First Name<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_1_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_28\" ><label class='gfield_label gform-field-label' for='input_1_28'>Spouse Last Name<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_1_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_118\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_118\" ><label class='gfield_label gform-field-label' for='input_1_118'>Spouse Age<\/label><div class='ginput_container ginput_container_number'><input name='input_118' id='input_1_118' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_124\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_124\" ><label class='gfield_label gform-field-label' for='input_1_124'>Spouse Disability<\/label><div class='ginput_container ginput_container_select'><select name='input_124' id='input_1_124' class='large gfield_select'  aria-describedby=\"gfield_description_1_124\"   aria-invalid=\"false\" ><option value='true' >Spouse is disabled<\/option><option value='true' >Spouse provide care to another disabled household member<\/option><option value='true' >Spouse is disabled and provides care to another disabled household member<\/option><option value='false' >Spouse  is neither disabled nor provides care to another household family member<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_124'>Are you disabled or do you care for someone else who is disabled?\n<\/div><\/div><fieldset id=\"field_1_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\" ><legend class='gfield_label gform-field-label' >Does your spouse receive Medicare?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_22'>\n\t\t\t<div class='gchoice gchoice_1_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='true'  id='choice_1_22_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_22\"   \/>\n\t\t\t\t\t<label for='choice_1_22_0' id='label_1_22_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='false'  id='choice_1_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_22_1' id='label_1_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_22'>Medicare is a federal health insurance that is available to people over 65 or people who have been deemed disabled for 2 or more years. \n<\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_197' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_197' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_1_6_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_6' class='gform_page' data-js='page-field-id-197' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_162\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_162\" >Household member information is important to determine eligibility for SNAP and Medicare assistance programs. <\/div><div id=\"field_1_54\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_54\" ><label class='gfield_label gform-field-label' for='input_1_54'>Not counting you or your spouse, how many relatives live with you and depend on you for at least one-half of their financial support?  Do not count yourself or your spouse.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_54' id='input_1_54' type='number' step='any'   value='0' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_1_54\" \/><\/div><div class='gfield_description' id='gfield_description_1_54'>A relative is defined as someone related to you by blood, adoption, or marriage.  The Extra Help program determines eligibility based on the household size of relatives that you provide at least one-half of their financial support.\n<\/div><\/div><div id=\"field_1_139\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_139\" ><label class='gfield_label gform-field-label' for='input_1_139'>Number of Child dependents aged 0-2 years old.<\/label><div class='ginput_container ginput_container_number'><input name='input_139' id='input_1_139' type='number' step='any'   value='0' class='large'    placeholder='0'  aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_138\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_138\" ><label class='gfield_label gform-field-label' for='input_1_138'>Number of Child dependents aged 3-18 years old.<\/label><div class='ginput_container ginput_container_number'><input name='input_138' id='input_1_138' type='number' step='any'   value='0' class='large'    placeholder='0'  aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_141\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_141\" ><label class='gfield_label gform-field-label' for='input_1_141'>How much do you spend on child dependant care costs?<\/label><div class='ginput_container ginput_container_number'><input name='input_141' id='input_1_141' type='number' step='any'   value='0' class='large'    placeholder='0'  aria-invalid=\"false\" aria-describedby=\"gfield_description_1_141\" \/><\/div><div class='gfield_description' id='gfield_description_1_141'>These items may include child-care and\/or education costs.<\/div><\/div><div id=\"field_1_55\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_55\" ><label class='gfield_label gform-field-label' for='input_1_55'>How many people live with you and share the cost of groceries and food with you?  If you live alone, please enter 1.  If you share meals with your spouse please enter 2.  If there are other&#039;s that live with you and share meal costs, please enter the total number of people.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_55' id='input_1_55' type='number' step='any' min='1'  value='1' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_55 gfield_description_1_55\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_55'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><div class='gfield_description' id='gfield_description_1_55'>SNAP benefits are determined by he amount of people the purchase and share meals together.<\/div><\/div><fieldset id=\"field_1_29\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_29\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please enter the full name and age of each additional person in the house.<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">First Name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Last Name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Age<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_29_cell1 gform-grid-col' data-label='First Name'><input aria-invalid='false'   aria-label='First Name, Row 1' data-aria-label-template='First Name, Row {0}' type='text' name='input_29[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_29_cell2 gform-grid-col' data-label='Last Name'><input aria-invalid='false'   aria-label='Last Name, Row 1' data-aria-label-template='Last Name, Row {0}' type='text' name='input_29[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_29_cell3 gform-grid-col' data-label='Age'><input aria-invalid='false'   aria-label='Age, Row 1' data-aria-label-template='Age, Row {0}' type='text' name='input_29[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_31' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_31' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"7\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"7\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_1_7_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_7' class='gform_page' data-js='page-field-id-31' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_1_30\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please thoroughly provide all monthly income from jobs, wages, and\/or salaries.<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Type<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Value<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_30_cell1 gform-grid-col' data-label='Income Type'><select name='input_30[]'   aria-invalid='false'  aria-describedby=\"gfield_description_1_30\" aria-label='Income Type, Row 1' data-aria-label-template='Income Type, Row {0}'><option value='Wages\/Earned Income' >Wages\/Earned Income<\/option><option value='Self-Employment Earnings' >Self-Employment Earnings<\/option><option value='Social Security' >Social Security<\/option><option value='Social Security Disability' >Social Security Disability<\/option><option value='Supplemental Security Income' >Supplemental Security Income<\/option><option value='Veterans&#039; Benefits' >Veterans&#039; Benefits<\/option><option value='Pension or Annuities' >Pension or Annuities<\/option><option value='Child Support' >Child Support<\/option><option value='Alimony' >Alimony<\/option><option value='Rental Income' >Rental Income<\/option><option value='Worker&#039;s Compensation' >Worker&#039;s Compensation<\/option><option value='Unemployment' >Unemployment<\/option><option value='Disability Payments (Not Social Security)' >Disability Payments (Not Social Security)<\/option><option value='Training Stipends (AmeriCorps)' >Training Stipends (AmeriCorps)<\/option><option value='In-Kind Support' >In-Kind Support<\/option><option value='Foster Care Payments' >Foster Care Payments<\/option><\/select><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_30_cell2 gform-grid-col' data-label='Income Value'><input aria-invalid='false'  aria-describedby=\"gfield_description_1_30\" aria-label='Income Value, Row 1' data-aria-label-template='Income Value, Row {0}' type='text' name='input_30[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_30'>Press the (+) to the right of the income to add additional sources of income.<\/div><\/fieldset><fieldset id=\"field_1_135\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_135\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please thoroughly provide all your monthly income from social security, retirement benefits, and all other income.<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Type<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Value<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_135_cell1 gform-grid-col' data-label='Income Type'><select name='input_135[]'   aria-invalid='false'  aria-describedby=\"gfield_description_1_135\" aria-label='Income Type, Row 1' data-aria-label-template='Income Type, Row {0}'><option value='Social Security' >Social Security<\/option><option value='Social Security Disability' >Social Security Disability<\/option><\/select><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_135_cell2 gform-grid-col' data-label='Income Value'><input aria-invalid='false'  aria-describedby=\"gfield_description_1_135\" aria-label='Income Value, Row 1' data-aria-label-template='Income Value, Row {0}' type='text' name='input_135[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_135'>Press the (+) to the right of the income to add additional sources of income.<\/div><\/fieldset><fieldset id=\"field_1_153\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_153\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please thoroughly provide all your gross income amounts, the sources of income.<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Type<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Value<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_153_cell1 gform-grid-col' data-label='Income Type'><select name='input_153[]'   aria-invalid='false'   aria-label='Income Type, Row 1' data-aria-label-template='Income Type, Row {0}'><option value='Supplemental Security Income' >Supplemental Security Income<\/option><option value='Veterans&#039; Benefits' >Veterans&#039; Benefits<\/option><option value='Pension or Annuities' >Pension or Annuities<\/option><option value='Child Support' >Child Support<\/option><option value='Alimony' >Alimony<\/option><option value='Rental Income' >Rental Income<\/option><option value='Worker&#039;s Compensation' >Worker&#039;s Compensation<\/option><option value='Unemployment' >Unemployment<\/option><option value='Disability Payments (Not Social Security)' >Disability Payments (Not Social Security)<\/option><\/select><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_153_cell2 gform-grid-col' data-label='Income Value'><input aria-invalid='false'   aria-label='Income Value, Row 1' data-aria-label-template='Income Value, Row {0}' type='text' name='input_153[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_134\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_134\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please thoroughly provide all your gross income amounts, the sources of income.<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Type<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Value<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_134_cell1 gform-grid-col' data-label='Income Type'><select name='input_134[]'   aria-invalid='false'   aria-label='Income Type, Row 1' data-aria-label-template='Income Type, Row {0}'><option value='Training Stipends (AmeriCorps)' >Training Stipends (AmeriCorps)<\/option><option value='In-Kind Support' >In-Kind Support<\/option><option value='Foster Care Payments' >Foster Care Payments<\/option><\/select><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_134_cell2 gform-grid-col' data-label='Income Value'><input aria-invalid='false'   aria-label='Income Value, Row 1' data-aria-label-template='Income Value, Row {0}' type='text' name='input_134[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_1_119\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_119\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_119'>Your Total Income<\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_1_119' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_137\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_137\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_137'>Your SNAP Income<\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_1_137' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_136\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_136\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_136'>Your Other Income<\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_1_136' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_154\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_154\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_154'>Your MPAP Income<\/label><div class='ginput_container ginput_container_text'><input name='input_154' id='input_1_154' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_120\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_120\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please thoroughly provide all your Spouse&#039;s monthly income from jobs, wages, and\/or salaries.<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Type<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Value<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_120_cell1 gform-grid-col' data-label='Income Type'><select name='input_120[]'   aria-invalid='false'  aria-describedby=\"gfield_description_1_120\" aria-label='Income Type, Row 1' data-aria-label-template='Income Type, Row {0}'><option value='Wages\/Earned Income' >Wages\/Earned Income<\/option><option value='Self-Employment Earnings' >Self-Employment Earnings<\/option><option value='Social Security' >Social Security<\/option><option value='Social Security Disability' >Social Security Disability<\/option><option value='Supplemental Security Income' >Supplemental Security Income<\/option><option value='Veterans&#039; Benefits' >Veterans&#039; Benefits<\/option><option value='Pension or Annuities' >Pension or Annuities<\/option><option value='Child Support' >Child Support<\/option><option value='Alimony' >Alimony<\/option><option value='Rental Income' >Rental Income<\/option><option value='Worker&#039;s Compensation' >Worker&#039;s Compensation<\/option><option value='Unemployment' >Unemployment<\/option><option value='Disability Payments (Not Social Security)' >Disability Payments (Not Social Security)<\/option><option value='Training Stipends (AmeriCorps)' >Training Stipends (AmeriCorps)<\/option><option value='In-Kind Support' >In-Kind Support<\/option><option value='Foster Care Payments' >Foster Care Payments<\/option><\/select><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_120_cell2 gform-grid-col' data-label='Income Value'><input aria-invalid='false'  aria-describedby=\"gfield_description_1_120\" aria-label='Income Value, Row 1' data-aria-label-template='Income Value, Row {0}' type='text' name='input_120[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_120'>Press the (+) to the right to add additional sources of income.<\/div><\/fieldset><fieldset id=\"field_1_131\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_131\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please thoroughly provide all your Spouse&#039;s monthly income from social security, retirement benefits, and all other income.<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Type<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Value<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_131_cell1 gform-grid-col' data-label='Income Type'><select name='input_131[]'   aria-invalid='false'  aria-describedby=\"gfield_description_1_131\" aria-label='Income Type, Row 1' data-aria-label-template='Income Type, Row {0}'><option value='Social Security' >Social Security<\/option><option value='Social Security Disability' >Social Security Disability<\/option><\/select><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_131_cell2 gform-grid-col' data-label='Income Value'><input aria-invalid='false'  aria-describedby=\"gfield_description_1_131\" aria-label='Income Value, Row 1' data-aria-label-template='Income Value, Row {0}' type='text' name='input_131[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_131'>Press the (+) to the right to add additional sources of income.<\/div><\/fieldset><fieldset id=\"field_1_155\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_155\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please thoroughly provide all your Spouse&#039;s gross income amounts, the sources of income.<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Type<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Value<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_155_cell1 gform-grid-col' data-label='Income Type'><select name='input_155[]'   aria-invalid='false'   aria-label='Income Type, Row 1' data-aria-label-template='Income Type, Row {0}'><option value='Supplemental Security Income' >Supplemental Security Income<\/option><option value='Veterans&#039; Benefits' >Veterans&#039; Benefits<\/option><option value='Pension or Annuities' >Pension or Annuities<\/option><option value='Child Support' >Child Support<\/option><option value='Alimony' >Alimony<\/option><option value='Rental Income' >Rental Income<\/option><option value='Worker&#039;s Compensation' >Worker&#039;s Compensation<\/option><option value='Unemployment' >Unemployment<\/option><option value='Disability Payments (Not Social Security)' >Disability Payments (Not Social Security)<\/option><\/select><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_155_cell2 gform-grid-col' data-label='Income Value'><input aria-invalid='false'   aria-label='Income Value, Row 1' data-aria-label-template='Income Value, Row {0}' type='text' name='input_155[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_130\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_130\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please thoroughly provide all your Spouse&#039;s gross income amounts, the sources of income.<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Type<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Value<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_130_cell1 gform-grid-col' data-label='Income Type'><select name='input_130[]'   aria-invalid='false'   aria-label='Income Type, Row 1' data-aria-label-template='Income Type, Row {0}'><option value='Training Stipends (AmeriCorps)' >Training Stipends (AmeriCorps)<\/option><option value='In-Kind Support' >In-Kind Support<\/option><option value='Foster Care Payments' >Foster Care Payments<\/option><\/select><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_130_cell2 gform-grid-col' data-label='Income Value'><input aria-invalid='false'   aria-label='Income Value, Row 1' data-aria-label-template='Income Value, Row {0}' type='text' name='input_130[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_1_123\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_123\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_123'>Spouse&#039;s Total Income<\/label><div class='ginput_container ginput_container_text'><input name='input_123' id='input_1_123' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_133\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_133\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_133'>Spouse&#039;s SNAP Income<\/label><div class='ginput_container ginput_container_text'><input name='input_133' id='input_1_133' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_132\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_132\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_132'>Spouse&#039;s OTHER Income<\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_1_132' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_156\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_156\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_156'>Spouse&#039;s MPAP Income<\/label><div class='ginput_container ginput_container_text'><input name='input_156' id='input_1_156' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_121\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_121\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please thoroughly provide all your Household&#039;s monthly income from jobs, wages, and\/or salaries.<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Type<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Value<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_121_cell1 gform-grid-col' data-label='Income Type'><select name='input_121[]'   aria-invalid='false'  aria-describedby=\"gfield_description_1_121\" aria-label='Income Type, Row 1' data-aria-label-template='Income Type, Row {0}'><option value='Wages\/Earned Income' >Wages\/Earned Income<\/option><option value='Self-Employment Earnings' >Self-Employment Earnings<\/option><\/select><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_121_cell2 gform-grid-col' data-label='Income Value'><input aria-invalid='false'  aria-describedby=\"gfield_description_1_121\" aria-label='Income Value, Row 1' data-aria-label-template='Income Value, Row {0}' type='text' name='input_121[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_121'>Press the (+) to add additional sources of income.<\/div><\/fieldset><fieldset id=\"field_1_125\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_125\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please thoroughly provide all your Household&#039;s monthly income from social security, retirement benefits, and all other income.<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Type<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Value<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_125_cell1 gform-grid-col' data-label='Income Type'><select name='input_125[]'   aria-invalid='false'  aria-describedby=\"gfield_description_1_125\" aria-label='Income Type, Row 1' data-aria-label-template='Income Type, Row {0}'><option value='Social Security' >Social Security<\/option><option value='Social Security Disability' >Social Security Disability<\/option><option value='Supplemental Security Income' >Supplemental Security Income<\/option><option value='Veterans&#039; Benefits' >Veterans&#039; Benefits<\/option><option value='Pension or Annuities' >Pension or Annuities<\/option><option value='Child Support' >Child Support<\/option><option value='Alimony' >Alimony<\/option><option value='Rental Income' >Rental Income<\/option><option value='Worker&#039;s Compensation' >Worker&#039;s Compensation<\/option><option value='Unemployment' >Unemployment<\/option><option value='Disability Payments (Not Social Security)' >Disability Payments (Not Social Security)<\/option><\/select><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_125_cell2 gform-grid-col' data-label='Income Value'><input aria-invalid='false'  aria-describedby=\"gfield_description_1_125\" aria-label='Income Value, Row 1' data-aria-label-template='Income Value, Row {0}' type='text' name='input_125[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_125'>Press the (+) to add additional sources of income.<\/div><\/fieldset><fieldset id=\"field_1_127\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_127\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please thoroughly provide all your Household gross income amounts, the sources of income.<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Type<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Income Value<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_127_cell1 gform-grid-col' data-label='Income Type'><select name='input_127[]'   aria-invalid='false'   aria-label='Income Type, Row 1' data-aria-label-template='Income Type, Row {0}'><option value='Training Stipends (AmeriCorps)' >Training Stipends (AmeriCorps)<\/option><option value='In-Kind Support' >In-Kind Support<\/option><option value='Foster Care Payments' >Foster Care Payments<\/option><\/select><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_127_cell2 gform-grid-col' data-label='Income Value'><input aria-invalid='false'   aria-label='Income Value, Row 1' data-aria-label-template='Income Value, Row {0}' type='text' name='input_127[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_1_122\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_122\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_122'>Household Total Income<\/label><div class='ginput_container ginput_container_text'><input name='input_122' id='input_1_122' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_129\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_129\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_129'>Household SNAP Income<\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_1_129' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_128\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_128\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_128'>Household OTHER Income<\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_1_128' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_32' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_32' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"8\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"8\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_1_8_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_8' class='gform_page' data-js='page-field-id-32' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_57\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_57\" ><h3 class=\"gsection_title\">Liquid Assets<\/h3><div class='gsection_description' id='gfield_description_1_57'>Please provide the following information as accurately as possible.  If you, and another household member, have separate resources, please add them together and provide the total.\n<\/div><\/div><div id=\"field_1_199\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_199\" ><\/div><div id=\"field_1_56\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_56\" ><label class='gfield_label gform-field-label' for='input_1_56'>Cash on Hand<\/label><div class='ginput_container ginput_container_number'><input name='input_56' id='input_1_56' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_58\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_58\" ><label class='gfield_label gform-field-label' for='input_1_58'>Checking\/Savings Accounts<\/label><div class='ginput_container ginput_container_number'><input name='input_58' id='input_1_58' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_72\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_72\" ><label class='gfield_label gform-field-label' for='input_1_72'>Stocks &amp; Retirement Savings such as Stocks, Bonds, Mutual Funds, or 401ks<\/label><div class='ginput_container ginput_container_number'><input name='input_72' id='input_1_72' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_200\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_200\" ><\/div><div id=\"field_1_62\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_62\" ><label class='gfield_label gform-field-label' for='input_1_62'>Spouse Cash on Hand<\/label><div class='ginput_container ginput_container_number'><input name='input_62' id='input_1_62' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_63\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_63\" ><label class='gfield_label gform-field-label' for='input_1_63'>Spouse Checking\/Savings Accounts<\/label><div class='ginput_container ginput_container_number'><input name='input_63' id='input_1_63' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_78\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_78\" ><label class='gfield_label gform-field-label' for='input_1_78'>Spouse Stocks &amp; Retirement Savings such as Stocks, Bonds, Mutual Funds, or 401ks<\/label><div class='ginput_container ginput_container_number'><input name='input_78' id='input_1_78' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_201\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_201\" ><\/div><div id=\"field_1_66\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_66\" ><label class='gfield_label gform-field-label' for='input_1_66'>Household Cash on Hand<\/label><div class='ginput_container ginput_container_number'><input name='input_66' id='input_1_66' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_70\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_70\" ><label class='gfield_label gform-field-label' for='input_1_70'>Household Checking\/Savings Accounts<\/label><div class='ginput_container ginput_container_number'><input name='input_70' id='input_1_70' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_92\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_92\" ><label class='gfield_label gform-field-label' for='input_1_92'>Household Stocks &amp; Retirement Savings such as Stocks, Bonds, Mutual Funds, or 401ks<\/label><div class='ginput_container ginput_container_number'><input name='input_92' id='input_1_92' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_71\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_71\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><h3 class=\"gsection_title\">Investment Assets<\/h3><div class='gsection_description' id='gfield_description_1_71'>Please provide the following information as accurately as possible.  If you, and another household member, have separate resources, please add them together and provide the total.\n<\/div><\/div><div id=\"field_1_90\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_90\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><h3 class=\"gsection_title\">Retirement Assets<\/h3><div class='gsection_description' id='gfield_description_1_90'>Please provide the following information as accurately as possible.  If you, and another household member, have separate resources, please add them together and provide the total.\n<\/div><\/div><div id=\"field_1_94\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_94\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_94'>Retirement Savings such as 401k or IRAs<\/label><div class='ginput_container ginput_container_number'><input name='input_94' id='input_1_94' type='number' step='any'   value='0' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_95\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_95\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_95'>Spouse Retirement Savings such as 401k or IRAs<\/label><div class='ginput_container ginput_container_number'><input name='input_95' id='input_1_95' type='number' step='any'   value='0' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_96\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_96\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_96'>Household Retirement Savings such as 401k or IRAs<\/label><div class='ginput_container ginput_container_number'><input name='input_96' id='input_1_96' type='number' step='any'   value='0' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_106\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_106\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><h3 class=\"gsection_title\">Trusts<\/h3><div class='gsection_description' id='gfield_description_1_106'>Please provide the following information as accurately as possible.  If you, and another household member, have separate resources, please add them together and provide the total.\n<\/div><\/div><div id=\"field_1_109\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_109\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_109'>Insurance Policies with a Cash Surrender Value.  Please put in the cash surrender value.<\/label><div class='ginput_container ginput_container_number'><input name='input_109' id='input_1_109' type='number' step='any'   value='0' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_108\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_108\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_108'>Spouse Insurance Policies with a Cash Surrender Value.  Please put in the cash surrender value.<\/label><div class='ginput_container ginput_container_number'><input name='input_108' id='input_1_108' type='number' step='any'   value='0' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_107\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_107\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_107'>Household Insurance Policies with a Cash Surrender Value.  Please put in the cash surrender value.<\/label><div class='ginput_container ginput_container_number'><input name='input_107' id='input_1_107' type='number' step='any'   value='0' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_1_202\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_202\" ><html><body><legend class=\"gfield_label gform-field-label\"><gftt-label class=\"gftt-label\">Do you own or are you buying a home?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/gftt-label><i id=\"gftt-1_202\" class=\"gftt-icon gform-theme__no-reset--el\" tabindex=\"0\" data-placement=\"se\"><\/i><div class=\"gftt-content\" id=\"gftt-1_202-wrap\" role=\"tooltip\" aria-hidden=\"false\"><div id=\"gftt-1_202-content\" data-tid=\"gftt-1_202\" aria-hidden=\"false\">If you have a mortgage on your home, choose \"yes.\"<\/div><\/div><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_1_202\">\n\t\t\t<div class=\"gchoice gchoice_1_202_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_202\" type=\"radio\" value=\"Yes\" id=\"choice_1_202_0\" onchange=\"gformToggleRadioOther( this )\" aria-describedby=\"gftt-1_202-wrap\">\n\t\t\t\t\t<label for=\"choice_1_202_0\" id=\"label_1_202_0\" class=\"gform-field-label gform-field-label--type-inline\">Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_1_202_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_202\" type=\"radio\" value=\"No\" id=\"choice_1_202_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_1_202_1\" id=\"label_1_202_1\" class=\"gform-field-label gform-field-label--type-inline\">No<\/label>\n\t\t\t<\/div><\/div><\/div><\/body><\/html><\/fieldset><div id=\"field_1_113\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_113\" ><h3 class=\"gsection_title\">Equity Value of Non-Home Real Property<\/h3><div class='gsection_description' id='gfield_description_1_113'>Please provide the following information as accurately as possible.  If you, and another household member, have separate resources, please add them together and provide the total.\n\nEquity is the total value of your home\/land minus the total amount you still owe on your home\/land.\n<\/div><\/div><div id=\"field_1_117\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_117\" ><label class='gfield_label gform-field-label' for='input_1_117'>Equity Value of your home.<\/label><div class='ginput_container ginput_container_number'><input name='input_117' id='input_1_117' type='number' step='any'   value='0' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_146\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_146\" ><label class='gfield_label gform-field-label' for='input_1_146'>Equity value of any additional homes or land.<\/label><div class='ginput_container ginput_container_number'><input name='input_146' id='input_1_146' type='number' step='any'   value='0' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_115\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_115\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_115'>Spouse Equity Value of your home.<\/label><div class='ginput_container ginput_container_number'><input name='input_115' id='input_1_115' type='number' step='any'   value='0' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_114\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_114\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_114'>Household Equity Value of your home.<\/label><div class='ginput_container ginput_container_number'><input name='input_114' id='input_1_114' type='number' step='any'   value='0' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_147\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_147\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_147'>Spouse Equity value of any additional homes or land.<\/label><div class='ginput_container ginput_container_number'><input name='input_147' id='input_1_147' type='number' step='any'   value='0' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_148\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_148\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_148'>Household Equity value of any additional homes or land.<\/label><div class='ginput_container ginput_container_number'><input name='input_148' id='input_1_148' type='number' step='any'   value='0' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_163' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"7\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"7\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_163' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"9\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"9\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_1_9_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_9' class='gform_page' data-js='page-field-id-163' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_164\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_164\" >Some programs count the value of additional vehicles as assets.  However, SNAP will exclude one vehicle from consideration, and Medicare Premium Assistance Programs will not count vehicles that are used for transportation.\n\n<a href=\"https:\/\/www.nada.org\/nada\/consumer-vehicle-values\">National Automobile Dealers Association (NADA) Pricing Guide<\/a><\/div><fieldset id=\"field_1_166\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_166\" ><legend class='gfield_label gform-field-label' >Does anyone in your household own a licensed vehicle?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_166'>\n\t\t\t<div class='gchoice gchoice_1_166_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_166' type='radio' value='Yes'  id='choice_1_166_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_166\"   \/>\n\t\t\t\t\t<label for='choice_1_166_0' id='label_1_166_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_166_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_166' type='radio' value='No'  id='choice_1_166_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_166_1' id='label_1_166_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_166'>Licensed vehicles include cars, trucks, motorcycles, boats, snowmobiles, trailers, and RVs.<\/div><\/fieldset><div id=\"field_1_167\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_167\" ><label class='gfield_label gform-field-label' for='input_1_167'>Highest Fair Market Value (FMV) licensed vehicle.<\/label><div class='ginput_container ginput_container_number'><input name='input_167' id='input_1_167' type='number' step='any'   value='0' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_description_1_167\" \/><\/div><div class='gfield_description' id='gfield_description_1_167'>A vehicle's Fair Market Value (FMV) is the average trade-in valude in the most recently published \"National Automobile Dealers Association (NADA) Guide\" minus any remaining amount owed on a loan.  See link above.<\/div><\/div><div id=\"field_1_168\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_168\" ><label class='gfield_label gform-field-label' for='input_1_168'>Second highest Fair Market Value (FMV) licensed vehicle.<\/label><div class='ginput_container ginput_container_number'><input name='input_168' id='input_1_168' type='number' step='any'   value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_description_1_168\" \/><\/div><div class='gfield_description' id='gfield_description_1_168'>Leave blank or zero if you don't own a second vehicle.<\/div><\/div><div id=\"field_1_169\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_169\" ><label class='gfield_label gform-field-label' for='input_1_169'>Third highest Fair Market Value (FMV) licensed vehicle.<\/label><div class='ginput_container ginput_container_number'><input name='input_169' id='input_1_169' type='number' step='any'   value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_description_1_169\" \/><\/div><div class='gfield_description' id='gfield_description_1_169'>Leave blank or zero if you don't own a third vehicle.<\/div><\/div><div id=\"field_1_170\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_170\" ><label class='gfield_label gform-field-label' for='input_1_170'>Fourth highest Fair Market Value (FMV) licensed vehicle.<\/label><div class='ginput_container ginput_container_number'><input name='input_170' id='input_1_170' type='number' step='any'   value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_description_1_170\" \/><\/div><div class='gfield_description' id='gfield_description_1_170'>Leave blank or zero if you don't own a fourth vehicle.<\/div><\/div><div id=\"field_1_172\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_172\" ><label class='gfield_label gform-field-label' for='input_1_172'>Additional Fair Market Value (FMV) of licensed vehicles<\/label><div class='ginput_container ginput_container_number'><input name='input_172' id='input_1_172' type='number' step='any'   value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_description_1_172\" \/><\/div><div class='gfield_description' id='gfield_description_1_172'>Do to the complexity of the interview, please include the Fair Market Value for the vehicles for household members.  Please add the values of the lowest valued vehicles owned by the household.\n\nPlease add the FMV of any and all remaining vehicles.  If you don't own any additional vehicles, please leave the field blank or zero.<\/div><\/div><div id=\"field_1_173\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_173\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_173'>Vehicle Asset Total HH = 1<\/label><div class='ginput_container ginput_container_number'><input name='input_173' id='input_1_173' type='text' step='any'   value='' class='large'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_177\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_177\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_177'>Vehicle Asset Total HH = 2<\/label><div class='ginput_container ginput_container_number'><input name='input_177' id='input_1_177' type='text' step='any'   value='' class='large'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_176\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_176\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_176'>Vehicle Asset Total HH = 3<\/label><div class='ginput_container ginput_container_number'><input name='input_176' id='input_1_176' type='text' step='any'   value='' class='large'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_175\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_175\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_175'>Vehicle Asset Total HH = 4<\/label><div class='ginput_container ginput_container_number'><input name='input_175' id='input_1_175' type='text' step='any'   value='' class='large'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_37' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"8\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"8\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_37' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"10\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"10\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_1_10_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_10' class='gform_page' data-js='page-field-id-37' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_39\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_39\" ><p>Please make a best estimation of monthly costs for the following utilities.<\/p><p>  If you do not pay for a utility out-of-pocket, please leave the value 0.\n<\/p><\/div><div id=\"field_1_38\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_38\" ><label class='gfield_label gform-field-label' for='input_1_38'>Gas\/Electricity<\/label><div class='ginput_container ginput_container_number'><input name='input_38' id='input_1_38' type='number' step='any'   value='' class='large'    placeholder='0'  aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_40\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_40\" ><label class='gfield_label gform-field-label' for='input_1_40'>Water<\/label><div class='ginput_container ginput_container_number'><input name='input_40' id='input_1_40' type='number' step='any'   value='' class='large'    placeholder='0'  aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_41\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_41\" ><label class='gfield_label gform-field-label' for='input_1_41'>Telephone<\/label><div class='ginput_container ginput_container_number'><input name='input_41' id='input_1_41' type='number' step='any'   value='' class='large'    placeholder='0'  aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_42\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_42\" ><label class='gfield_label gform-field-label' for='input_1_42'>Trash<\/label><div class='ginput_container ginput_container_number'><input name='input_42' id='input_1_42' type='number' step='any'   value='' class='large'    placeholder='0'  aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_44\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_44\" >How much do you pay for the following medical related expenses:    \n<\/div><div id=\"field_1_43\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_43\" ><label class='gfield_label gform-field-label' for='input_1_43'>Health Insurance\/Medicare Premium<\/label><div class='ginput_container ginput_container_number'><input name='input_43' id='input_1_43' type='number' step='any'   value='' class='large'    placeholder='0'  aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_45\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_45\" ><label class='gfield_label gform-field-label' for='input_1_45'>Other Monthly Medical Costs<\/label><div class='ginput_container ginput_container_number'><input name='input_45' id='input_1_45' type='number' step='any'   value='' class='large'    placeholder='0'  aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_46\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_46\" >How much do you pay for the following household expenses?\n<\/div><div id=\"field_1_47\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_47\" ><label class='gfield_label gform-field-label' for='input_1_47'>Rent\/Mortgage<\/label><div class='ginput_container ginput_container_number'><input name='input_47' id='input_1_47' type='number' step='any'   value='' class='large'    placeholder='0'  aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_48\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_48\" ><label class='gfield_label gform-field-label' for='input_1_48'>House Insurance<\/label><div class='ginput_container ginput_container_number'><input name='input_48' id='input_1_48' type='number' step='any'   value='' class='large'    placeholder='0'  aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_49\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_49\" ><label class='gfield_label gform-field-label' for='input_1_49'>HOA Fee<\/label><div class='ginput_container ginput_container_number'><input name='input_49' id='input_1_49' type='number' step='any'   value='' class='large'    placeholder='0'  aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_50\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_50\" ><label class='gfield_label gform-field-label' for='input_1_50'>Housing Taxes<\/label><div class='ginput_container ginput_container_number'><input name='input_50' id='input_1_50' type='number' step='any'   value='' class='large'    placeholder='0'  aria-invalid=\"false\"  \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_140' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"9\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"9\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_140' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"11\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"11\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_1_11_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_11' class='gform_page' data-js='page-field-id-140' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_51\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_51\" ><p>We thank you for completing the interview.  Momentarily, you will receive an email with a print out of your eligibility and instructions with how to apply for your eligible programs.    <\/p>                                                         <p>It is important to know that this is an estimate based on the interpretation of the Ohio Administrative Code.  <\/p><p>If you are over 60 and an Ohio resident, and would like to discuss the results with an attorney, please call our legal helpline to schedule an appointment.  (513) 345-4160.\n<\/p><\/div><div id=\"field_1_142\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_142\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_142'>SNAPNETINCOME<\/label><div class='ginput_container ginput_container_number'><input name='input_142' id='input_1_142' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_151\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_151\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_151'>SNAP Eligible<\/label><div class='ginput_container ginput_container_text'><input name='input_151' id='input_1_151' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_204\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_204\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_204'>Separate SNAP Household<\/label><div class='ginput_container ginput_container_text'><input name='input_204' id='input_1_204' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_204\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_1_204'>Allows post to final data explaining that user might be eligible for a separate AG determination and to re-run the formula with just their marital assets and income.<\/div><\/div><div id=\"field_1_152\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_152\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_152'>SNAP Benefits<\/label><div class='ginput_container ginput_container_text'><input name='input_152' id='input_1_152' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_190\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_190\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_190'>MedicaidEligible<\/label><div class='ginput_container ginput_container_text'><input name='input_190' id='input_1_190' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_191\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_191\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_191'>MPARP Results<\/label><div class='ginput_container ginput_container_text'><input name='input_191' id='input_1_191' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_192\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_192\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_192'>LISTYPE<\/label><div class='ginput_container ginput_container_text'><input name='input_192' id='input_1_192' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_193\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_193\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_193'>MPAPAsset<\/label><div class='ginput_container ginput_container_text'><input name='input_193' id='input_1_193' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_161\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_161\" ><\/div><div id=\"field_1_198\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_198\" ><\/div><div id=\"field_1_205\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_205\" ><label class='gfield_label gform-field-label' for='input_1_205'>Phone<\/label><div class='ginput_container'><input name='input_205' id='input_1_205' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_205'>This field is for validation purposes and should be left unchanged.<\/div><\/div><\/div><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_1' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> <button type='button'  id='gform_save_1_footer_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;} jQuery(\"#gform_save_1\").val(1); jQuery(\"#gform_1\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input 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