/*jslint nomen:false, debug:true, evil:true, vars:false, browser:true, forin:true, undef:false, white:false */
/**
* Includes a Form with javascript
* @param {Object} formId
* @param {Object} initialHeight
* @param {Object} iframeCode
*/
function FrameBuilder (formId, appendTo, initialHeight, iframeCode){
this.formId = formId;
this.initialHeight = initialHeight;
this.iframeCode = iframeCode;
this.frame = null;
this.timeInterval= 200;
this.appendTo = appendTo || false;
// initialize function for object
this.init = function(){
this.createFrame();
this.addFrameContent(this.iframeCode);
};
// Create the frame
this.createFrame = function(){
var htmlCode = "<"+"iframe src=\"\" allowtransparency=\"true\" frameborder=\"0\" name=\""+this.formId+"\" id=\""+this.formId+"\" style=\"width:100%; height:"+this.initialHeight+"px; border:none;\" scrolling=\"no\">";
if(this.appendTo === false){
document.write(htmlCode);
}else{
var tmp = document.createElement('div');
tmp.innerHTML = htmlCode;
var a = this.appendTo;
document.getElementById(a).appendChild(tmp.firstChild);
}
// also get the frame for future use.
this.frame = document.getElementById(this.formId);
// set the time on the on load event of the frame
this.addEvent(this.frame, 'load', this.bindMethod(this.setTimer, this));
};
// add event function for different browsers
this.addEvent = function( obj, type, fn ) {
if ( obj.attachEvent ) {
obj["e"+type+fn] = fn;
obj[type+fn] = function() { obj["e"+type+fn]( window.event ); };
obj.attachEvent( "on"+type, obj[type+fn] );
}
else{
obj.addEventListener( type, fn, false );
}
};
this.addFrameContent = function (string){
string = string.replace(new RegExp('src\\=\\"[^"]*captcha.php\"><\/scr'+'ipt>', 'gim'), 'src="http://api.recaptcha.net/js/recaptcha_ajax.js"><'+'div id="recaptcha_div"><'+'/div>'+
'<'+'style>#recaptcha_logo{ display:none;} #recaptcha_tagline{display:none;} #recaptcha_table{border:none !important;} .recaptchatable .recaptcha_image_cell, #recaptcha_table{ background-color:transparent !important; } <'+'/style>'+
'<'+'script defer="defer"> window.onload = function(){ Recaptcha.create("6Ld9UAgAAAAAAMon8zjt30tEZiGQZ4IIuWXLt1ky", "recaptcha_div", {theme: "clean",tabindex: 0,callback: function (){'+
'if (document.getElementById("uword")) { document.getElementById("uword").parentNode.removeChild(document.getElementById("uword")); } if (window["validate"] !== undefined) { if (document.getElementById("recaptcha_response_field")){ document.getElementById("recaptcha_response_field").onblur = function(){ validate(document.getElementById("recaptcha_response_field"), "Required"); } } } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_challenge_field")[0].setAttribute("name", "anum"); } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_response_field")[0].setAttribute("name", "qCap"); }}})'+
' }<'+'/script>');
string = string.replace(/(type="text\/javascript">)\s+(validate\(\"[^"]*"\);)/, '$1 jTime = setInterval(function(){if("validate" in window){$2clearTimeout(jTime);}}, 1000);');
var frameDocument = (this.frame.contentWindow) ? this.frame.contentWindow : (this.frame.contentDocument.document) ? this.frame.contentDocument.document : this.frame.contentDocument;
frameDocument.document.open();
frameDocument.document.write(string);
setTimeout( function(){
frameDocument.document.close();
try{
if('JotFormFrameLoaded' in window){
JotFormFrameLoaded();
}
}catch(e){}
},200);
};
this.setTimer = function(){
var self = this;
this.interval = setTimeout(function(){self.changeHeight();},this.timeInterval);
};
this.changeHeight = function (){
var actualHeight = this.getBodyHeight();
var currentHeight = this.getViewPortHeight();
if(actualHeight === undefined){
this.frame.style.height = "100%";
if(!this.frame.style.minHeight){
this.frame.style.minHeight = "300px";
}
}else if (Math.abs(actualHeight - currentHeight) > 18){
this.frame.style.height = (actualHeight)+"px";
}
this.setTimer();
};
this.bindMethod = function(method, scope) {
return function() {
method.apply(scope,arguments);
};
};
this.getBodyHeight = function (){
var height;
var scrollHeight;
var offsetHeight;
try{ // Prevent IE from throw errors
if (this.frame.contentWindow.document.height){
height = this.frame.contentWindow.document.height;
//Emre: to prevent "iframe height" problem (61059)
if (this.frame.contentWindow.document.body.scrollHeight){
height = scrollHeight = this.frame.contentWindow.document.body.scrollHeight;
}
if (this.frame.contentWindow.document.body.offsetHeight){
height = offsetHeight = this.frame.contentWindow.document.body.offsetHeight;
}
} else if (this.frame.contentWindow.document.body){
if (this.frame.contentWindow.document.body.scrollHeight){
height = scrollHeight = this.frame.contentWindow.document.body.scrollHeight;
}
if (this.frame.contentWindow.document.body.offsetHeight){
height = offsetHeight = this.frame.contentWindow.document.body.offsetHeight;
}
if (scrollHeight && offsetHeight){
height = Math.max(scrollHeight, offsetHeight);
}
}
}catch(e){ }
return height;
};
this.getViewPortHeight = function(){
var height = 0;
try{ // Prevent IE from throw errors
if (this.frame.contentWindow.window.innerHeight)
{
height = this.frame.contentWindow.window.innerHeight - 18;
}
else if ((this.frame.contentWindow.document.documentElement) &&
(this.frame.contentWindow.document.documentElement.clientHeight))
{
height = this.frame.contentWindow.document.documentElement.clientHeight;
}
else if ((this.frame.contentWindow.document.body) &&
(this.frame.contentWindow.document.body.clientHeight))
{
height = this.frame.contentWindow.document.body.clientHeight;
}
}catch(e){ }
return height;
};
this.init();
}
FrameBuilder.get = [];
var i10454010547 = new FrameBuilder("10454010547", false, "", "\n\n\n\n\nForm<\/title>\n<link href=\"http:\/\/max.jotfor.ms\/min\/g=formCss?3.0.2622\" rel=\"stylesheet\" type=\"text\/css\" \/>\n<style type=\"text\/css\">\n .form-label{\n width:450px !important;\n }\n .form-label-left{\n width:450px !important;\n }\n .form-line{\n padding:3px;\n }\n .form-label-right{\n width:450px !important;\n }\n body, html{\n margin:0;\n padding:0;\n background:#FCF7D9;\n }\n\n .form-all{\n margin:0px auto;\n padding-top:20px;\n width:800px;\n background:#FCF7D9;\n color:#242424 !important;\n font-family:\"Trebuchet MS\";\n font-size:14px;\n }\n<\/style>\n\n<script src=\"http:\/\/max.jotfor.ms\/min\/g=jotform?3.0.2622\" type=\"text\/javascript\"><\/script>\n<script type=\"text\/javascript\">\n var jsTime = setInterval(function(){try{\n JotForm.jsForm = true;\n\n JotForm.setConditions([{\"action\":{\"field\":\"35\",\"visibility\":\"Hide\"},\"link\":\"Any\",\"terms\":[{\"field\":\"31\",\"operator\":\"isEmpty\",\"value\":false}],\"type\":\"field\"},{\"action\":{\"field\":\"35\",\"visibility\":\"Show\"},\"link\":\"Any\",\"terms\":[{\"field\":\"31\",\"operator\":\"isFilled\",\"value\":false}],\"type\":\"field\"},{\"action\":{\"field\":\"30\",\"visibility\":\"Hide\"},\"link\":\"Any\",\"terms\":[{\"field\":\"31\",\"operator\":\"isEmpty\",\"value\":false}],\"type\":\"field\"},{\"action\":{\"field\":\"30\",\"visibility\":\"Show\"},\"link\":\"Any\",\"terms\":[{\"field\":\"31\",\"operator\":\"isFilled\",\"value\":false}],\"type\":\"field\"},{\"action\":{\"field\":\"34\",\"visibility\":\"Hide\"},\"link\":\"Any\",\"terms\":[{\"field\":\"31\",\"operator\":\"isEmpty\",\"value\":false}],\"type\":\"field\"},{\"action\":{\"field\":\"34\",\"visibility\":\"Show\"},\"link\":\"Any\",\"terms\":[{\"field\":\"31\",\"operator\":\"isFilled\",\"value\":false}],\"type\":\"field\"},{\"action\":{\"field\":\"18\",\"visibility\":\"Hide\"},\"link\":\"Any\",\"terms\":[{\"field\":\"21\",\"operator\":\"isEmpty\",\"value\":false}],\"type\":\"field\"},{\"action\":{\"field\":\"38\",\"visibility\":\"Hide\"},\"link\":\"Any\",\"terms\":[{\"field\":\"21\",\"operator\":\"isEmpty\",\"value\":false}],\"type\":\"field\"},{\"action\":{\"field\":\"20\",\"visibility\":\"Hide\"},\"link\":\"Any\",\"terms\":[{\"field\":\"21\",\"operator\":\"isEmpty\",\"value\":false}],\"type\":\"field\"},{\"action\":{\"field\":\"19\",\"visibility\":\"Hide\"},\"link\":\"Any\",\"terms\":[{\"field\":\"21\",\"operator\":\"isEmpty\",\"value\":false}],\"type\":\"field\"},{\"action\":{\"field\":\"18\",\"visibility\":\"Hide\"},\"link\":\"Any\",\"terms\":[{\"field\":\"21\",\"operator\":\"notEquals\",\"value\":\"Yes\"}],\"type\":\"field\"},{\"action\":{\"field\":\"38\",\"visibility\":\"Hide\"},\"link\":\"Any\",\"terms\":[{\"field\":\"21\",\"operator\":\"notEquals\",\"value\":\"Yes\"}],\"type\":\"field\"},{\"action\":{\"field\":\"20\",\"visibility\":\"Hide\"},\"link\":\"Any\",\"terms\":[{\"field\":\"21\",\"operator\":\"notEquals\",\"value\":\"Yes\"}],\"type\":\"field\"},{\"action\":{\"field\":\"19\",\"visibility\":\"Hide\"},\"link\":\"Any\",\"terms\":[{\"field\":\"21\",\"operator\":\"notEquals\",\"value\":\"Yes\"}],\"type\":\"field\"},{\"action\":{\"field\":\"21\",\"visibility\":\"Hide\"},\"link\":\"Any\",\"terms\":[{\"field\":\"17\",\"operator\":\"equals\",\"value\":\"No\"}],\"type\":\"field\"},{\"action\":{\"field\":\"21\",\"visibility\":\"Hide\"},\"link\":\"Any\",\"terms\":[{\"field\":\"17\",\"operator\":\"isEmpty\",\"value\":false}],\"type\":\"field\"},{\"action\":{\"field\":\"21\",\"visibility\":\"Hide\"},\"link\":\"Any\",\"terms\":[{\"field\":\"17\",\"operator\":\"notEquals\",\"value\":\"Yes\"}],\"type\":\"field\"}]);\n JotForm.init(function(){\n $('input_9').hint('ex: myname@example.com');\n });\n\n clearInterval(jsTime);\n }catch(e){}}, 1000);\n<\/script>\n<\/head>\n<body>\n<form class=\"jotform-form\" action=\"http:\/\/submit.jotform.com\/submit.php\" method=\"post\" name=\"form_10454010547\" id=\"10454010547\" accept-charset=\"utf-8\">\n <input type=\"hidden\" name=\"formID\" value=\"10454010547\" \/>\n <div class=\"form-all\">\n <ul class=\"form-section\">\n <li class=\"form-line\" id=\"id_3\">\n <label class=\"form-label-right\" id=\"label_3\" for=\"input_3\">\n What is the applicant's first and last name?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_3\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" type=\"text\" size=\"10\" name=\"q3_whatIs3[first]\" id=\"first_3\" \/>\n <label class=\"form-sub-label\" for=\"first_3\" id=\"sublabel_first\"> First Name <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" type=\"text\" size=\"15\" name=\"q3_whatIs3[last]\" id=\"last_3\" \/>\n <label class=\"form-sub-label\" for=\"last_3\" id=\"sublabel_last\"> Last Name <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_39\">\n <label class=\"form-label-right\" id=\"label_39\" for=\"input_39\">\n What is the applicant' street address?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_39\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_39\" name=\"q39_whatIs39\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_40\">\n <label class=\"form-label-right\" id=\"label_40\" for=\"input_40\">\n What is the applicant's city?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_40\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_40\" name=\"q40_whatIs40\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_41\">\n <label class=\"form-label-right\" id=\"label_41\" for=\"input_41\">\n What is the applicant's state?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_41\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_41\" name=\"q41_whatIs41\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_32\">\n <label class=\"form-label-right\" id=\"label_32\" for=\"input_32\">\n What is the applicant's home Zip Code?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_32\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required, Numeric]\" id=\"input_32\" name=\"q32_whatIs\" size=\"5\" maxlength=\"5\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_31\">\n <label class=\"form-label-right\" id=\"label_31\" for=\"input_31\">\n Best phone number to reach you?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_31\" class=\"form-input\"><span class=\"form-sub-label-container\"><input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_31\" name=\"q31_bestPhone31\" size=\"13\" maxlength=\"12\" \/>\n <label class=\"form-sub-label\" for=\"input_31\"> 000-000-0000 <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_35\">\n <label class=\"form-label-right\" id=\"label_35\" for=\"input_35\"> Best time to reach you at this number? <\/label>\n <div id=\"cid_35\" class=\"form-input\">\n <select class=\"form-dropdown\" style=\"width:150px\" id=\"input_35\" name=\"q35_bestTime35\">\n <option> <\/option>\n <option value=\"Morning\"> Morning <\/option>\n <option value=\"Afternoon\"> Afternoon <\/option>\n <option value=\"Evening\"> Evening <\/option>\n <option value=\"Weekend\"> Weekend <\/option>\n <option value=\"Anytime\"> Anytime <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_30\">\n <label class=\"form-label-right\" id=\"label_30\" for=\"input_30\"> Any other phone number to reach you? <\/label>\n <div id=\"cid_30\" class=\"form-input\"><span class=\"form-sub-label-container\"><input type=\"text\" class=\"form-textbox\" id=\"input_30\" name=\"q30_anyOther\" size=\"13\" maxlength=\"12\" \/>\n <label class=\"form-sub-label\" for=\"input_30\"> 000-000-0000 <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_34\">\n <label class=\"form-label-right\" id=\"label_34\" for=\"input_34\"> Best time to reach you at this other number? <\/label>\n <div id=\"cid_34\" class=\"form-input\">\n <select class=\"form-dropdown\" style=\"width:150px\" id=\"input_34\" name=\"q34_bestTime34\">\n <option> <\/option>\n <option value=\"Morning\"> Morning <\/option>\n <option value=\"Afternoon\"> Afternoon <\/option>\n <option value=\"Evening\"> Evening <\/option>\n <option value=\"Weekend\"> Weekend <\/option>\n <option value=\"Anytime\"> Anytime <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_9\">\n <label class=\"form-label-right\" id=\"label_9\" for=\"input_9\">\n What is your email address?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_9\" class=\"form-input\">\n <input type=\"email\" class=\"form-textbox validate[required, Email]\" id=\"input_9\" name=\"q9_whatIs9\" size=\"30\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_29\">\n <label class=\"form-label-right\" id=\"label_29\" for=\"input_29\"> What is the applicant\u2019s relationship to you? <\/label>\n <div id=\"cid_29\" class=\"form-input\"><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" style=\"width:150px\" id=\"input_29\" name=\"q29_whatIs29\">\n <option> <\/option>\n <option value=\"Self\"> Self <\/option>\n <option value=\"Wife\"> Wife <\/option>\n <option value=\"Husband\"> Husband <\/option>\n <option value=\"Mother\"> Mother <\/option>\n <option value=\"Father\"> Father <\/option>\n <option value=\"Daughter\"> Daughter <\/option>\n <option value=\"Son\"> Son <\/option>\n <option value=\"Sister\"> Sister <\/option>\n <option value=\"Brother\"> Brother <\/option>\n <option value=\"Friend\"> Friend <\/option>\n <option value=\"Other\"> Other <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_29\"> Please Select <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_11\">\n <label class=\"form-label-right\" id=\"label_11\" for=\"input_11\">\n Is the applicant already receiving Social Security benefits?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_11\" class=\"form-input\">\n <div class=\"form-multiple-column\"><span class=\"form-radio-item\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_11_0\" name=\"q11_isThe\" value=\"Yes\" \/>\n <label for=\"input_11_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_11_1\" name=\"q11_isThe\" value=\"No\" \/>\n <label for=\"input_11_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_12\">\n <label class=\"form-label-right\" id=\"label_12\" for=\"input_12\">\n What is the applicant\u2019s birth date?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_12\" class=\"form-input\"><span class=\"form-sub-label-container\"><select class=\"form-dropdown validate[required]\" name=\"q12_whatIs12[month]\" id=\"input_12_month\">\n <option> <\/option>\n <option value=\"January\"> January <\/option>\n <option value=\"February\"> February <\/option>\n <option value=\"March\"> March <\/option>\n <option value=\"April\"> April <\/option>\n <option value=\"May\"> May <\/option>\n <option value=\"June\"> June <\/option>\n <option value=\"July\"> July <\/option>\n <option value=\"August\"> August <\/option>\n <option value=\"September\"> September <\/option>\n <option value=\"October\"> October <\/option>\n <option value=\"November\"> November <\/option>\n <option value=\"December\"> December <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_12_month\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown validate[required]\" name=\"q12_whatIs12[day]\" id=\"input_12_day\">\n <option> <\/option>\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <option value=\"11\"> 11 <\/option>\n <option value=\"12\"> 12 <\/option>\n <option value=\"13\"> 13 <\/option>\n <option value=\"14\"> 14 <\/option>\n <option value=\"15\"> 15 <\/option>\n <option value=\"16\"> 16 <\/option>\n <option value=\"17\"> 17 <\/option>\n <option value=\"18\"> 18 <\/option>\n <option value=\"19\"> 19 <\/option>\n <option value=\"20\"> 20 <\/option>\n <option value=\"21\"> 21 <\/option>\n <option value=\"22\"> 22 <\/option>\n <option value=\"23\"> 23 <\/option>\n <option value=\"24\"> 24 <\/option>\n <option value=\"25\"> 25 <\/option>\n <option value=\"26\"> 26 <\/option>\n <option value=\"27\"> 27 <\/option>\n <option value=\"28\"> 28 <\/option>\n <option value=\"29\"> 29 <\/option>\n <option value=\"30\"> 30 <\/option>\n <option value=\"31\"> 31 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_12_day\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown validate[required]\" name=\"q12_whatIs12[year]\" id=\"input_12_year\">\n <option> <\/option>\n <option value=\"2016\"> 2016 <\/option>\n <option value=\"2015\"> 2015 <\/option>\n <option value=\"2014\"> 2014 <\/option>\n <option value=\"2013\"> 2013 <\/option>\n <option value=\"2012\"> 2012 <\/option>\n <option value=\"2011\"> 2011 <\/option>\n <option value=\"2010\"> 2010 <\/option>\n <option value=\"2009\"> 2009 <\/option>\n <option value=\"2008\"> 2008 <\/option>\n <option value=\"2007\"> 2007 <\/option>\n <option value=\"2006\"> 2006 <\/option>\n <option value=\"2005\"> 2005 <\/option>\n <option value=\"2004\"> 2004 <\/option>\n <option value=\"2003\"> 2003 <\/option>\n <option value=\"2002\"> 2002 <\/option>\n <option value=\"2001\"> 2001 <\/option>\n <option value=\"2000\"> 2000 <\/option>\n <option value=\"1999\"> 1999 <\/option>\n <option value=\"1998\"> 1998 <\/option>\n <option value=\"1997\"> 1997 <\/option>\n <option value=\"1996\"> 1996 <\/option>\n <option value=\"1995\"> 1995 <\/option>\n <option value=\"1994\"> 1994 <\/option>\n <option value=\"1993\"> 1993 <\/option>\n <option value=\"1992\"> 1992 <\/option>\n <option value=\"1991\"> 1991 <\/option>\n <option value=\"1990\"> 1990 <\/option>\n <option value=\"1989\"> 1989 <\/option>\n <option value=\"1988\"> 1988 <\/option>\n <option value=\"1987\"> 1987 <\/option>\n <option value=\"1986\"> 1986 <\/option>\n <option value=\"1985\"> 1985 <\/option>\n <option value=\"1984\"> 1984 <\/option>\n <option value=\"1983\"> 1983 <\/option>\n <option value=\"1982\"> 1982 <\/option>\n <option value=\"1981\"> 1981 <\/option>\n <option value=\"1980\"> 1980 <\/option>\n <option value=\"1979\"> 1979 <\/option>\n <option value=\"1978\"> 1978 <\/option>\n <option value=\"1977\"> 1977 <\/option>\n <option value=\"1976\"> 1976 <\/option>\n <option value=\"1975\"> 1975 <\/option>\n <option value=\"1974\"> 1974 <\/option>\n <option value=\"1973\"> 1973 <\/option>\n <option value=\"1972\"> 1972 <\/option>\n <option value=\"1971\"> 1971 <\/option>\n <option value=\"1970\"> 1970 <\/option>\n <option value=\"1969\"> 1969 <\/option>\n <option value=\"1968\"> 1968 <\/option>\n <option value=\"1967\"> 1967 <\/option>\n <option value=\"1966\"> 1966 <\/option>\n <option value=\"1965\"> 1965 <\/option>\n <option value=\"1964\"> 1964 <\/option>\n <option value=\"1963\"> 1963 <\/option>\n <option value=\"1962\"> 1962 <\/option>\n <option value=\"1961\"> 1961 <\/option>\n <option value=\"1960\"> 1960 <\/option>\n <option value=\"1959\"> 1959 <\/option>\n <option value=\"1958\"> 1958 <\/option>\n <option value=\"1957\"> 1957 <\/option>\n <option value=\"1956\"> 1956 <\/option>\n <option value=\"1955\"> 1955 <\/option>\n <option value=\"1954\"> 1954 <\/option>\n <option value=\"1953\"> 1953 <\/option>\n <option value=\"1952\"> 1952 <\/option>\n <option value=\"1951\"> 1951 <\/option>\n <option value=\"1950\"> 1950 <\/option>\n <option value=\"1949\"> 1949 <\/option>\n <option value=\"1948\"> 1948 <\/option>\n <option value=\"1947\"> 1947 <\/option>\n <option value=\"1946\"> 1946 <\/option>\n <option value=\"1945\"> 1945 <\/option>\n <option value=\"1944\"> 1944 <\/option>\n <option value=\"1943\"> 1943 <\/option>\n <option value=\"1942\"> 1942 <\/option>\n <option value=\"1941\"> 1941 <\/option>\n <option value=\"1940\"> 1940 <\/option>\n <option value=\"1939\"> 1939 <\/option>\n <option value=\"1938\"> 1938 <\/option>\n <option value=\"1937\"> 1937 <\/option>\n <option value=\"1936\"> 1936 <\/option>\n <option value=\"1935\"> 1935 <\/option>\n <option value=\"1934\"> 1934 <\/option>\n <option value=\"1933\"> 1933 <\/option>\n <option value=\"1932\"> 1932 <\/option>\n <option value=\"1931\"> 1931 <\/option>\n <option value=\"1930\"> 1930 <\/option>\n <option value=\"1929\"> 1929 <\/option>\n <option value=\"1928\"> 1928 <\/option>\n <option value=\"1927\"> 1927 <\/option>\n <option value=\"1926\"> 1926 <\/option>\n <option value=\"1925\"> 1925 <\/option>\n <option value=\"1924\"> 1924 <\/option>\n <option value=\"1923\"> 1923 <\/option>\n <option value=\"1922\"> 1922 <\/option>\n <option value=\"1921\"> 1921 <\/option>\n <option value=\"1920\"> 1920 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_12_year\" id=\"sublabel_year\"> Year <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_28\">\n <label class=\"form-label-right\" id=\"label_28\" for=\"input_28\"> What is the applicant\u2019s marital status? <\/label>\n <div id=\"cid_28\" class=\"form-input\"><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" style=\"width:150px\" id=\"input_28\" name=\"q28_whatIs28\">\n <option> <\/option>\n <option value=\"Single\"> Single <\/option>\n <option value=\"Married\"> Married <\/option>\n <option value=\"Divorced\"> Divorced <\/option>\n <option value=\"Widowed\"> Widowed <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_28\"> Please Select <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_14\">\n <label class=\"form-label-right\" id=\"label_14\" for=\"input_14\">\n What health condition prevents the applicant from working?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_14\" class=\"form-input\">\n <textarea id=\"input_14\" class=\"form-textarea validate[required]\" name=\"q14_whatHealth14\" cols=\"35\" rows=\"8\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_15\">\n <label class=\"form-label-right\" id=\"label_15\" for=\"input_15\">\n Will the applicant be unable to work full-time for at least one year?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_15\" class=\"form-input\">\n <div class=\"form-multiple-column\"><span class=\"form-radio-item\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_15_0\" name=\"q15_willThe\" value=\"Yes\" \/>\n <label for=\"input_15_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_15_1\" name=\"q15_willThe\" value=\"No\" \/>\n <label for=\"input_15_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_37\">\n <label class=\"form-label-right\" id=\"label_37\" for=\"input_37\"> Will a doctor verify that the applicant is unable to work? <\/label>\n <div id=\"cid_37\" class=\"form-input\"><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" style=\"width:150px\" id=\"input_37\" name=\"q37_willA37\">\n <option> <\/option>\n <option value=\"Yes\"> Yes <\/option>\n <option value=\"No\"> No <\/option>\n <option value=\"Unsure\"> Unsure <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_37\"> Please Select <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_17\">\n <label class=\"form-label-right\" id=\"label_17\" for=\"input_17\">\n Has the applicant ever applied for Disability Benefits?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_17\" class=\"form-input\">\n <div class=\"form-multiple-column\"><span class=\"form-radio-item\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_17_0\" name=\"q17_hasThe\" value=\"Yes\" \/>\n <label for=\"input_17_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_17_1\" name=\"q17_hasThe\" value=\"No\" \/>\n <label for=\"input_17_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_21\">\n <label class=\"form-label-right\" id=\"label_21\" for=\"input_21\"> Was the applicant's disability benefits denied? <\/label>\n <div id=\"cid_21\" class=\"form-input\">\n <div class=\"form-multiple-column\"><span class=\"form-radio-item\"><input type=\"radio\" class=\"form-radio\" id=\"input_21_0\" name=\"q21_wasThe\" value=\"Yes\" \/>\n <label for=\"input_21_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\"><input type=\"radio\" class=\"form-radio\" id=\"input_21_1\" name=\"q21_wasThe\" value=\"No\" \/>\n <label for=\"input_21_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_18\">\n <label class=\"form-label-right\" id=\"label_18\" for=\"input_18\"> If yes, when was the applicant last denied? <\/label>\n <div id=\"cid_18\" class=\"form-input\"><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q18_ifYes18[month]\" id=\"input_18_month\">\n <option> <\/option>\n <option value=\"January\"> January <\/option>\n <option value=\"February\"> February <\/option>\n <option value=\"March\"> March <\/option>\n <option value=\"April\"> April <\/option>\n <option value=\"May\"> May <\/option>\n <option value=\"June\"> June <\/option>\n <option value=\"July\"> July <\/option>\n <option value=\"August\"> August <\/option>\n <option value=\"September\"> September <\/option>\n <option value=\"October\"> October <\/option>\n <option value=\"November\"> November <\/option>\n <option value=\"December\"> December <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_18_month\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q18_ifYes18[day]\" id=\"input_18_day\">\n <option> <\/option>\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <option value=\"11\"> 11 <\/option>\n <option value=\"12\"> 12 <\/option>\n <option value=\"13\"> 13 <\/option>\n <option value=\"14\"> 14 <\/option>\n <option value=\"15\"> 15 <\/option>\n <option value=\"16\"> 16 <\/option>\n <option value=\"17\"> 17 <\/option>\n <option value=\"18\"> 18 <\/option>\n <option value=\"19\"> 19 <\/option>\n <option value=\"20\"> 20 <\/option>\n <option value=\"21\"> 21 <\/option>\n <option value=\"22\"> 22 <\/option>\n <option value=\"23\"> 23 <\/option>\n <option value=\"24\"> 24 <\/option>\n <option value=\"25\"> 25 <\/option>\n <option value=\"26\"> 26 <\/option>\n <option value=\"27\"> 27 <\/option>\n <option value=\"28\"> 28 <\/option>\n <option value=\"29\"> 29 <\/option>\n <option value=\"30\"> 30 <\/option>\n <option value=\"31\"> 31 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_18_day\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q18_ifYes18[year]\" id=\"input_18_year\">\n <option> <\/option>\n <option value=\"2016\"> 2016 <\/option>\n <option value=\"2015\"> 2015 <\/option>\n <option value=\"2014\"> 2014 <\/option>\n <option value=\"2013\"> 2013 <\/option>\n <option value=\"2012\"> 2012 <\/option>\n <option value=\"2011\"> 2011 <\/option>\n <option value=\"2010\"> 2010 <\/option>\n <option value=\"2009\"> 2009 <\/option>\n <option value=\"2008\"> 2008 <\/option>\n <option value=\"2007\"> 2007 <\/option>\n <option value=\"2006\"> 2006 <\/option>\n <option value=\"2005\"> 2005 <\/option>\n <option value=\"2004\"> 2004 <\/option>\n <option value=\"2003\"> 2003 <\/option>\n <option value=\"2002\"> 2002 <\/option>\n <option value=\"2001\"> 2001 <\/option>\n <option value=\"2000\"> 2000 <\/option>\n <option value=\"1999\"> 1999 <\/option>\n <option value=\"1998\"> 1998 <\/option>\n <option value=\"1997\"> 1997 <\/option>\n <option value=\"1996\"> 1996 <\/option>\n <option value=\"1995\"> 1995 <\/option>\n <option value=\"1994\"> 1994 <\/option>\n <option value=\"1993\"> 1993 <\/option>\n <option value=\"1992\"> 1992 <\/option>\n <option value=\"1991\"> 1991 <\/option>\n <option value=\"1990\"> 1990 <\/option>\n <option value=\"1989\"> 1989 <\/option>\n <option value=\"1988\"> 1988 <\/option>\n <option value=\"1987\"> 1987 <\/option>\n <option value=\"1986\"> 1986 <\/option>\n <option value=\"1985\"> 1985 <\/option>\n <option value=\"1984\"> 1984 <\/option>\n <option value=\"1983\"> 1983 <\/option>\n <option value=\"1982\"> 1982 <\/option>\n <option value=\"1981\"> 1981 <\/option>\n <option value=\"1980\"> 1980 <\/option>\n <option value=\"1979\"> 1979 <\/option>\n <option value=\"1978\"> 1978 <\/option>\n <option value=\"1977\"> 1977 <\/option>\n <option value=\"1976\"> 1976 <\/option>\n <option value=\"1975\"> 1975 <\/option>\n <option value=\"1974\"> 1974 <\/option>\n <option value=\"1973\"> 1973 <\/option>\n <option value=\"1972\"> 1972 <\/option>\n <option value=\"1971\"> 1971 <\/option>\n <option value=\"1970\"> 1970 <\/option>\n <option value=\"1969\"> 1969 <\/option>\n <option value=\"1968\"> 1968 <\/option>\n <option value=\"1967\"> 1967 <\/option>\n <option value=\"1966\"> 1966 <\/option>\n <option value=\"1965\"> 1965 <\/option>\n <option value=\"1964\"> 1964 <\/option>\n <option value=\"1963\"> 1963 <\/option>\n <option value=\"1962\"> 1962 <\/option>\n <option value=\"1961\"> 1961 <\/option>\n <option value=\"1960\"> 1960 <\/option>\n <option value=\"1959\"> 1959 <\/option>\n <option value=\"1958\"> 1958 <\/option>\n <option value=\"1957\"> 1957 <\/option>\n <option value=\"1956\"> 1956 <\/option>\n <option value=\"1955\"> 1955 <\/option>\n <option value=\"1954\"> 1954 <\/option>\n <option value=\"1953\"> 1953 <\/option>\n <option value=\"1952\"> 1952 <\/option>\n <option value=\"1951\"> 1951 <\/option>\n <option value=\"1950\"> 1950 <\/option>\n <option value=\"1949\"> 1949 <\/option>\n <option value=\"1948\"> 1948 <\/option>\n <option value=\"1947\"> 1947 <\/option>\n <option value=\"1946\"> 1946 <\/option>\n <option value=\"1945\"> 1945 <\/option>\n <option value=\"1944\"> 1944 <\/option>\n <option value=\"1943\"> 1943 <\/option>\n <option value=\"1942\"> 1942 <\/option>\n <option value=\"1941\"> 1941 <\/option>\n <option value=\"1940\"> 1940 <\/option>\n <option value=\"1939\"> 1939 <\/option>\n <option value=\"1938\"> 1938 <\/option>\n <option value=\"1937\"> 1937 <\/option>\n <option value=\"1936\"> 1936 <\/option>\n <option value=\"1935\"> 1935 <\/option>\n <option value=\"1934\"> 1934 <\/option>\n <option value=\"1933\"> 1933 <\/option>\n <option value=\"1932\"> 1932 <\/option>\n <option value=\"1931\"> 1931 <\/option>\n <option value=\"1930\"> 1930 <\/option>\n <option value=\"1929\"> 1929 <\/option>\n <option value=\"1928\"> 1928 <\/option>\n <option value=\"1927\"> 1927 <\/option>\n <option value=\"1926\"> 1926 <\/option>\n <option value=\"1925\"> 1925 <\/option>\n <option value=\"1924\"> 1924 <\/option>\n <option value=\"1923\"> 1923 <\/option>\n <option value=\"1922\"> 1922 <\/option>\n <option value=\"1921\"> 1921 <\/option>\n <option value=\"1920\"> 1920 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_18_year\" id=\"sublabel_year\"> Year <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_38\">\n <label class=\"form-label-right\" id=\"label_38\" for=\"input_38\"> Did the applicant appeal? <\/label>\n <div id=\"cid_38\" class=\"form-input\">\n <div class=\"form-multiple-column\"><span class=\"form-radio-item\"><input type=\"radio\" class=\"form-radio\" id=\"input_38_0\" name=\"q38_didThe\" value=\"Yes\" \/>\n <label for=\"input_38_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\"><input type=\"radio\" class=\"form-radio\" id=\"input_38_1\" name=\"q38_didThe\" value=\"No\" \/>\n <label for=\"input_38_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_20\">\n <label class=\"form-label-right\" id=\"label_20\" for=\"input_20\"> If yes, when did the applicant appeal? <\/label>\n <div id=\"cid_20\" class=\"form-input\"><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q20_ifYes20[month]\" id=\"input_20_month\">\n <option> <\/option>\n <option value=\"January\"> January <\/option>\n <option value=\"February\"> February <\/option>\n <option value=\"March\"> March <\/option>\n <option value=\"April\"> April <\/option>\n <option value=\"May\"> May <\/option>\n <option value=\"June\"> June <\/option>\n <option value=\"July\"> July <\/option>\n <option value=\"August\"> August <\/option>\n <option value=\"September\"> September <\/option>\n <option value=\"October\"> October <\/option>\n <option value=\"November\"> November <\/option>\n <option value=\"December\"> December <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_20_month\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q20_ifYes20[day]\" id=\"input_20_day\">\n <option> <\/option>\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <option value=\"11\"> 11 <\/option>\n <option value=\"12\"> 12 <\/option>\n <option value=\"13\"> 13 <\/option>\n <option value=\"14\"> 14 <\/option>\n <option value=\"15\"> 15 <\/option>\n <option value=\"16\"> 16 <\/option>\n <option value=\"17\"> 17 <\/option>\n <option value=\"18\"> 18 <\/option>\n <option value=\"19\"> 19 <\/option>\n <option value=\"20\"> 20 <\/option>\n <option value=\"21\"> 21 <\/option>\n <option value=\"22\"> 22 <\/option>\n <option value=\"23\"> 23 <\/option>\n <option value=\"24\"> 24 <\/option>\n <option value=\"25\"> 25 <\/option>\n <option value=\"26\"> 26 <\/option>\n <option value=\"27\"> 27 <\/option>\n <option value=\"28\"> 28 <\/option>\n <option value=\"29\"> 29 <\/option>\n <option value=\"30\"> 30 <\/option>\n <option value=\"31\"> 31 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_20_day\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q20_ifYes20[year]\" id=\"input_20_year\">\n <option> <\/option>\n <option value=\"2016\"> 2016 <\/option>\n <option value=\"2015\"> 2015 <\/option>\n <option value=\"2014\"> 2014 <\/option>\n <option value=\"2013\"> 2013 <\/option>\n <option value=\"2012\"> 2012 <\/option>\n <option value=\"2011\"> 2011 <\/option>\n <option value=\"2010\"> 2010 <\/option>\n <option value=\"2009\"> 2009 <\/option>\n <option value=\"2008\"> 2008 <\/option>\n <option value=\"2007\"> 2007 <\/option>\n <option value=\"2006\"> 2006 <\/option>\n <option value=\"2005\"> 2005 <\/option>\n <option value=\"2004\"> 2004 <\/option>\n <option value=\"2003\"> 2003 <\/option>\n <option value=\"2002\"> 2002 <\/option>\n <option value=\"2001\"> 2001 <\/option>\n <option value=\"2000\"> 2000 <\/option>\n <option value=\"1999\"> 1999 <\/option>\n <option value=\"1998\"> 1998 <\/option>\n <option value=\"1997\"> 1997 <\/option>\n <option value=\"1996\"> 1996 <\/option>\n <option value=\"1995\"> 1995 <\/option>\n <option value=\"1994\"> 1994 <\/option>\n <option value=\"1993\"> 1993 <\/option>\n <option value=\"1992\"> 1992 <\/option>\n <option value=\"1991\"> 1991 <\/option>\n <option value=\"1990\"> 1990 <\/option>\n <option value=\"1989\"> 1989 <\/option>\n <option value=\"1988\"> 1988 <\/option>\n <option value=\"1987\"> 1987 <\/option>\n <option value=\"1986\"> 1986 <\/option>\n <option value=\"1985\"> 1985 <\/option>\n <option value=\"1984\"> 1984 <\/option>\n <option value=\"1983\"> 1983 <\/option>\n <option value=\"1982\"> 1982 <\/option>\n <option value=\"1981\"> 1981 <\/option>\n <option value=\"1980\"> 1980 <\/option>\n <option value=\"1979\"> 1979 <\/option>\n <option value=\"1978\"> 1978 <\/option>\n <option value=\"1977\"> 1977 <\/option>\n <option value=\"1976\"> 1976 <\/option>\n <option value=\"1975\"> 1975 <\/option>\n <option value=\"1974\"> 1974 <\/option>\n <option value=\"1973\"> 1973 <\/option>\n <option value=\"1972\"> 1972 <\/option>\n <option value=\"1971\"> 1971 <\/option>\n <option value=\"1970\"> 1970 <\/option>\n <option value=\"1969\"> 1969 <\/option>\n <option value=\"1968\"> 1968 <\/option>\n <option value=\"1967\"> 1967 <\/option>\n <option value=\"1966\"> 1966 <\/option>\n <option value=\"1965\"> 1965 <\/option>\n <option value=\"1964\"> 1964 <\/option>\n <option value=\"1963\"> 1963 <\/option>\n <option value=\"1962\"> 1962 <\/option>\n <option value=\"1961\"> 1961 <\/option>\n <option value=\"1960\"> 1960 <\/option>\n <option value=\"1959\"> 1959 <\/option>\n <option value=\"1958\"> 1958 <\/option>\n <option value=\"1957\"> 1957 <\/option>\n <option value=\"1956\"> 1956 <\/option>\n <option value=\"1955\"> 1955 <\/option>\n <option value=\"1954\"> 1954 <\/option>\n <option value=\"1953\"> 1953 <\/option>\n <option value=\"1952\"> 1952 <\/option>\n <option value=\"1951\"> 1951 <\/option>\n <option value=\"1950\"> 1950 <\/option>\n <option value=\"1949\"> 1949 <\/option>\n <option value=\"1948\"> 1948 <\/option>\n <option value=\"1947\"> 1947 <\/option>\n <option value=\"1946\"> 1946 <\/option>\n <option value=\"1945\"> 1945 <\/option>\n <option value=\"1944\"> 1944 <\/option>\n <option value=\"1943\"> 1943 <\/option>\n <option value=\"1942\"> 1942 <\/option>\n <option value=\"1941\"> 1941 <\/option>\n <option value=\"1940\"> 1940 <\/option>\n <option value=\"1939\"> 1939 <\/option>\n <option value=\"1938\"> 1938 <\/option>\n <option value=\"1937\"> 1937 <\/option>\n <option value=\"1936\"> 1936 <\/option>\n <option value=\"1935\"> 1935 <\/option>\n <option value=\"1934\"> 1934 <\/option>\n <option value=\"1933\"> 1933 <\/option>\n <option value=\"1932\"> 1932 <\/option>\n <option value=\"1931\"> 1931 <\/option>\n <option value=\"1930\"> 1930 <\/option>\n <option value=\"1929\"> 1929 <\/option>\n <option value=\"1928\"> 1928 <\/option>\n <option value=\"1927\"> 1927 <\/option>\n <option value=\"1926\"> 1926 <\/option>\n <option value=\"1925\"> 1925 <\/option>\n <option value=\"1924\"> 1924 <\/option>\n <option value=\"1923\"> 1923 <\/option>\n <option value=\"1922\"> 1922 <\/option>\n <option value=\"1921\"> 1921 <\/option>\n <option value=\"1920\"> 1920 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_20_year\" id=\"sublabel_year\"> Year <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_19\">\n <label class=\"form-label-right\" id=\"label_19\" for=\"input_19\"> Was the applicant denied the appeal? <\/label>\n <div id=\"cid_19\" class=\"form-input\">\n <div class=\"form-multiple-column\"><span class=\"form-radio-item\"><input type=\"radio\" class=\"form-radio\" id=\"input_19_0\" name=\"q19_wasThe19\" value=\"Yes\" \/>\n <label for=\"input_19_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\"><input type=\"radio\" class=\"form-radio\" id=\"input_19_1\" name=\"q19_wasThe19\" value=\"No\" \/>\n <label for=\"input_19_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_22\">\n <label class=\"form-label-right\" id=\"label_22\" for=\"input_22\">\n Is an attorney already assisting the applicant with this matter?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_22\" class=\"form-input\">\n <div class=\"form-multiple-column\"><span class=\"form-radio-item\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_22_0\" name=\"q22_isAn\" value=\"Yes\" \/>\n <label for=\"input_22_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_22_1\" name=\"q22_isAn\" value=\"No\" \/>\n <label for=\"input_22_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_36\">\n <label class=\"form-label-right\" id=\"label_36\" for=\"input_36\"> Additional Comments? (optional) <\/label>\n <div id=\"cid_36\" class=\"form-input\">\n <textarea id=\"input_36\" class=\"form-textarea\" name=\"q36_additionalComments\" cols=\"35\" rows=\"5\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_33\">\n <div id=\"cid_33\" class=\"form-input-wide\">\n <div id=\"text_33\" class=\"form-html\">\n <p style=\"text-align: center;\"><span style=\"font-size: x-small;\">* Required Field<\/span>\n <\/p>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_25\">\n <div id=\"cid_25\" class=\"form-input-wide\">\n <div style=\"text-align:center\" class=\"form-buttons-wrapper\">\n <button id=\"input_25\" type=\"submit\" class=\"form-submit-button\">\n Submit Form\n <\/button>\n \n <button id=\"input_reset_25\" type=\"reset\" class=\"form-submit-reset\">\n Clear Form\n <\/button>\n <\/div>\n <\/div>\n <\/li>\n <li style=\"display:none\">\n Should be Empty:\n <input type=\"text\" name=\"website\" value=\"\" \/>\n <\/li>\n <\/ul>\n <\/div>\n <input type=\"hidden\" id=\"simple_spc\" name=\"simple_spc\" value=\"10454010547\" \/>\n <script type=\"text\/javascript\">\n document.getElementById(\"si\" + \"mple\" + \"_spc\").value = \"10454010547-10454010547\";\n <\/script>\n <input type=\"hidden\" class=\"form-hidden\" value=\"www.WinSSD.com\" id=\"input_26\" name=\"q26_source26\" \/>\n<\/form><\/body>\n<\/html>\n");