{"id":6793,"date":"2023-09-19T16:03:33","date_gmt":"2023-09-19T16:03:33","guid":{"rendered":"http:\/\/johng283.sg-host.com\/?page_id=6793"},"modified":"2023-09-19T16:03:33","modified_gmt":"2023-09-19T16:03:33","slug":"river-oak-apartments-rental-application","status":"publish","type":"page","link":"https:\/\/www.readingha.org\/es\/river-oak-apartments-rental-application\/","title":{"rendered":"Solicitud de alquiler de apartamentos en River Oak"},"content":{"rendered":"<p>[fusion_builder_container type=&#8221;flex&#8221; hundred_percent=&#8221;no&#8221; hundred_percent_height=&#8221;no&#8221; min_height_medium=&#8221;&#8221; min_height_small=&#8221;&#8221; min_height=&#8221;&#8221; hundred_percent_height_scroll=&#8221;no&#8221; align_content=&#8221;stretch&#8221; flex_align_items=&#8221;flex-start&#8221; flex_justify_content=&#8221;flex-start&#8221; flex_wrap_medium=&#8221;&#8221; flex_wrap_small=&#8221;&#8221; flex_wrap=&#8221;wrap&#8221; flex_column_spacing=&#8221;&#8221; 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class='gform-body gform_body'><div id='gform_fields_22' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_22_62\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_62'><span class='gform-field-label__text'>URL<\/span><\/label><div class='ginput_container'><input name='input_62' id='input_22_62' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_22_62'>This field is for validation purposes and should be left unchanged.<\/div><\/div><fieldset id=\"field_22_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Applicant Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_22_1'>\n                            \n                            <span id='input_22_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_22_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_22_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_22_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_22_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_22_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_22_3\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_22_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_22_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_22_3_1' value=''    aria-required='true'    \/>\n                                        <label for='input_22_3_1' id='input_22_3_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_22_3_2_container' >\n                                        <input type='text' name='input_3.2' id='input_22_3_2' value=''     aria-required='false'   \/>\n                                        <label for='input_22_3_2' id='input_22_3_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_22_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_22_3_3' value=''    aria-required='true'    \/>\n                                    <label for='input_22_3_3' id='input_22_3_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_22_3_4_container' >\n                                        <input type='text' name='input_3.4' id='input_22_3_4' value=''      aria-required='true'    \/>\n                                        <label for='input_22_3_4' id='input_22_3_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_22_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_22_3_5' value=''    aria-required='true'    \/>\n                                    <label for='input_22_3_5' id='input_22_3_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_3.6' id='input_22_3_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_22_4\" class=\"gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_4'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_4' id='input_22_4' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_22_5\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_5'><span class='gform-field-label__text'>Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_22_5' type='tel' value='' class='large'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_22_6\" class=\"gfield gfield--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\"  ><h2>River Oak Apartments, 125 River Oak Drive, Reading, PA 19601<\/h2>\n<ul>\n  <li> Resident is responsible for electric.<\/li>\n  <li>For consideration of your application your family's total gross monthly income must be <strong>(3) three times the monthly rent plus the average monthly cost of electric<\/strong>. <\/li>\n<\/ul>\n<h3>2 Bedroom - $806.00\/month x 3 months = $2418.00 + Average Utility Cost - $170.00\/ month = $2588.00<\/h3>\n<h3>3 Bedroom - $934.00\/month x 3 months = $2,802.00 + Average Utility Cost - $250.00\/month = $3,052.00<\/h3>\n<p>RHA occupancy standards are two persons per bedroom.  The maximum number of people in a 2 bedroom is 4, and the maximum number of people in a 3 bedroom is 6.  Exceeding the maximum may disqualify your application. <\/p>\n<\/div><fieldset id=\"field_22_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Please select the bedroom size you are applying for:<\/span><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_22_28'>\n\t\t\t<div class='gchoice gchoice_22_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='2 Bedroom'  id='choice_22_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_28_0' id='label_22_28_0' class='gform-field-label gform-field-label--type-inline'>2 Bedroom<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='3 Bedroom'  id='choice_22_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_28_1' id='label_22_28_1' class='gform-field-label gform-field-label--type-inline'>3 Bedroom<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_22_25\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_25'><span class='gform-field-label__text'>Number of Household Members<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_22_25'>Choose the number of household members then enter their information. Up to six household members.<\/div><div class='ginput_container ginput_container_select'><select name='input_25' id='input_22_25' class='medium gfield_select'  aria-describedby=\"gfield_description_22_25\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' >Select...<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><\/select><\/div><\/div><div id=\"field_22_9\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_22_26\" class=\"gfield gfield--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\"  ><h2>Household Member 1<\/h2><\/div><fieldset id=\"field_22_10\" class=\"gfield gfield--type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_22_10'>\n                            \n                            <span id='input_22_10_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_10.3' id='input_22_10_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_22_10_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_22_10_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_10.4' id='input_22_10_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_22_10_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_22_10_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_10.6' id='input_22_10_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_22_10_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_22_12\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Date of Birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_22_12' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_22_12_1_container'><label for='input_22_12_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_12[]' id='input_22_12_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_22_12_2_container'><label for='input_22_12_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_12[]' id='input_22_12_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_22_12_3_container'><label for='input_22_12_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_12[]' id='input_22_12_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_22_14\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Source of Income<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_22_14'><div class='gchoice gchoice_22_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='Social Security'  id='choice_22_14_1'   aria-describedby=\"gfield_description_22_14\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_22_14_1' id='label_22_14_1' class='gform-field-label gform-field-label--type-inline'>Social Security<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='SSI'  id='choice_22_14_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_14_2' id='label_22_14_2' class='gform-field-label gform-field-label--type-inline'>SSI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_14_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.3' type='checkbox'  value='Cash Assistance'  id='choice_22_14_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_14_3' id='label_22_14_3' class='gform-field-label gform-field-label--type-inline'>Cash Assistance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_14_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.4' type='checkbox'  value='Wages'  id='choice_22_14_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_14_4' id='label_22_14_4' class='gform-field-label gform-field-label--type-inline'>Wages<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_14_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.5' type='checkbox'  value='Unemployment Compensation'  id='choice_22_14_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_14_5' id='label_22_14_5' class='gform-field-label gform-field-label--type-inline'>Unemployment Compensation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_14_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.6' type='checkbox'  value='Child Support'  id='choice_22_14_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_14_6' id='label_22_14_6' class='gform-field-label gform-field-label--type-inline'>Child Support<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_14_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.7' type='checkbox'  value='Pension'  id='choice_22_14_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_14_7' id='label_22_14_7' class='gform-field-label gform-field-label--type-inline'>Pension<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_14_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.8' type='checkbox'  value='Workers Compensation'  id='choice_22_14_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_14_8' id='label_22_14_8' class='gform-field-label gform-field-label--type-inline'>Workers Compensation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_14_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.9' type='checkbox'  value='Veterans Benefits'  id='choice_22_14_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_14_9' id='label_22_14_9' class='gform-field-label gform-field-label--type-inline'>Veterans Benefits<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_14_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.11' type='checkbox'  value='Investment Income (interest, CDs, stocks\/bonds)'  id='choice_22_14_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_14_11' id='label_22_14_11' class='gform-field-label gform-field-label--type-inline'>Investment Income (interest, CDs, stocks\/bonds)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_14_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.12' type='checkbox'  value='Other'  id='choice_22_14_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_14_12' id='label_22_14_12' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_22_14'>Check all that apply<\/div><\/fieldset><div id=\"field_22_15\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_15'><span class='gform-field-label__text'>Employer<\/span><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_15' id='input_22_15' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_22_29\" class=\"gfield gfield--type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_29'><span class='gform-field-label__text'>Montly Gross Income<\/span><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_29' id='input_22_29' type='text' step='any'   value='' class='medium'    placeholder='0000.00' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_22_29\" \/><\/div><div class='gfield_description' id='gfield_description_22_29'>Enter only numbers.<\/div><\/div><div id=\"field_22_18\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_22_27\" class=\"gfield gfield--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\"  ><h2>Household Member 2<\/h2><\/div><fieldset id=\"field_22_19\" class=\"gfield gfield--type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_22_19'>\n                            \n                            <span id='input_22_19_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_19.3' id='input_22_19_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_22_19_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_22_19_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_19.4' id='input_22_19_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_22_19_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_22_19_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_19.6' id='input_22_19_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_22_19_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_22_20\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Date of Birth<\/span><\/legend><div id='input_22_20' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_22_20_1_container'><label for='input_22_20_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_20[]' id='input_22_20_1'   aria-required='false'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_22_20_2_container'><label for='input_22_20_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_20[]' id='input_22_20_2'   aria-required='false'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_22_20_3_container'><label for='input_22_20_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_20[]' id='input_22_20_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_22_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Source of Income<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_22_21'><div class='gchoice gchoice_22_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Social Security'  id='choice_22_21_1'   aria-describedby=\"gfield_description_22_21\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_22_21_1' id='label_22_21_1' class='gform-field-label gform-field-label--type-inline'>Social Security<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='SSI'  id='choice_22_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_21_2' id='label_22_21_2' class='gform-field-label gform-field-label--type-inline'>SSI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='Cash Assistance'  id='choice_22_21_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_21_3' id='label_22_21_3' class='gform-field-label gform-field-label--type-inline'>Cash Assistance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_21_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.4' type='checkbox'  value='Wages'  id='choice_22_21_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_21_4' id='label_22_21_4' class='gform-field-label gform-field-label--type-inline'>Wages<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_21_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.5' type='checkbox'  value='Unemployment Compensation'  id='choice_22_21_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_21_5' id='label_22_21_5' class='gform-field-label gform-field-label--type-inline'>Unemployment Compensation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_21_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.6' type='checkbox'  value='Child Support'  id='choice_22_21_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_21_6' id='label_22_21_6' class='gform-field-label gform-field-label--type-inline'>Child Support<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_21_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.7' type='checkbox'  value='Pension'  id='choice_22_21_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_21_7' id='label_22_21_7' class='gform-field-label gform-field-label--type-inline'>Pension<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_21_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.8' type='checkbox'  value='Workers Compensation'  id='choice_22_21_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_21_8' id='label_22_21_8' class='gform-field-label gform-field-label--type-inline'>Workers Compensation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_21_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.9' type='checkbox'  value='Veterans Benefits'  id='choice_22_21_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_21_9' id='label_22_21_9' class='gform-field-label gform-field-label--type-inline'>Veterans Benefits<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_21_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.11' type='checkbox'  value='Investment Income (interest, CDs, stocks\/bonds)'  id='choice_22_21_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_21_11' id='label_22_21_11' class='gform-field-label gform-field-label--type-inline'>Investment Income (interest, CDs, stocks\/bonds)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_21_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.12' type='checkbox'  value='Other'  id='choice_22_21_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_21_12' id='label_22_21_12' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_22_21'>Check all that apply<\/div><\/fieldset><div id=\"field_22_22\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_22'><span class='gform-field-label__text'>Employer<\/span><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_22' id='input_22_22' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_22_30\" class=\"gfield gfield--type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_30'><span class='gform-field-label__text'>Montly Gross Income<\/span><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_30' id='input_22_30' type='text' step='any'   value='' class='medium'    placeholder='0000.00' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_22_30\" \/><\/div><div class='gfield_description' id='gfield_description_22_30'>Enter only numbers.<\/div><\/div><div id=\"field_22_34\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_22_35\" class=\"gfield gfield--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\"  ><h2>Household Member 3<\/h2><\/div><fieldset id=\"field_22_36\" class=\"gfield gfield--type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_22_36'>\n                            \n                            <span id='input_22_36_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_36.3' id='input_22_36_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_22_36_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_22_36_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_36.4' id='input_22_36_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_22_36_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_22_36_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_36.6' id='input_22_36_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_22_36_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_22_37\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Date of Birth<\/span><\/legend><div id='input_22_37' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_22_37_1_container'><label for='input_22_37_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_37[]' id='input_22_37_1'   aria-required='false'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_22_37_2_container'><label for='input_22_37_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_37[]' id='input_22_37_2'   aria-required='false'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_22_37_3_container'><label for='input_22_37_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_37[]' id='input_22_37_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_22_38\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Source of Income<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_22_38'><div class='gchoice gchoice_22_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='Social Security'  id='choice_22_38_1'   aria-describedby=\"gfield_description_22_38\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_22_38_1' id='label_22_38_1' class='gform-field-label gform-field-label--type-inline'>Social Security<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_38_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.2' type='checkbox'  value='SSI'  id='choice_22_38_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_38_2' id='label_22_38_2' class='gform-field-label gform-field-label--type-inline'>SSI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_38_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.3' type='checkbox'  value='Cash Assistance'  id='choice_22_38_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_38_3' id='label_22_38_3' class='gform-field-label gform-field-label--type-inline'>Cash Assistance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_38_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.4' type='checkbox'  value='Wages'  id='choice_22_38_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_38_4' id='label_22_38_4' class='gform-field-label gform-field-label--type-inline'>Wages<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_38_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.5' type='checkbox'  value='Unemployment Compensation'  id='choice_22_38_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_38_5' id='label_22_38_5' class='gform-field-label gform-field-label--type-inline'>Unemployment Compensation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_38_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.6' type='checkbox'  value='Child Support'  id='choice_22_38_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_38_6' id='label_22_38_6' class='gform-field-label gform-field-label--type-inline'>Child Support<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_38_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.7' type='checkbox'  value='Pension'  id='choice_22_38_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_38_7' id='label_22_38_7' class='gform-field-label gform-field-label--type-inline'>Pension<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_38_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.8' type='checkbox'  value='Workers Compensation'  id='choice_22_38_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_38_8' id='label_22_38_8' class='gform-field-label gform-field-label--type-inline'>Workers Compensation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_38_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.9' type='checkbox'  value='Veterans Benefits'  id='choice_22_38_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_38_9' id='label_22_38_9' class='gform-field-label gform-field-label--type-inline'>Veterans Benefits<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_38_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.11' type='checkbox'  value='Investment Income (interest, CDs, stocks\/bonds)'  id='choice_22_38_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_38_11' id='label_22_38_11' class='gform-field-label gform-field-label--type-inline'>Investment Income (interest, CDs, stocks\/bonds)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_38_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.12' type='checkbox'  value='Other'  id='choice_22_38_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_38_12' id='label_22_38_12' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_22_38'>Check all that apply<\/div><\/fieldset><div id=\"field_22_39\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_39'><span class='gform-field-label__text'>Employer<\/span><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_39' id='input_22_39' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_22_40\" class=\"gfield gfield--type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_40'><span class='gform-field-label__text'>Montly Gross Income<\/span><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_40' id='input_22_40' type='text' step='any'   value='' class='medium'    placeholder='0000.00' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_22_40\" \/><\/div><div class='gfield_description' id='gfield_description_22_40'>Enter only numbers.<\/div><\/div><div id=\"field_22_41\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_22_42\" class=\"gfield gfield--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\"  ><h2>Household Member 4<\/h2><\/div><fieldset id=\"field_22_43\" class=\"gfield gfield--type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_22_43'>\n                            \n                            <span id='input_22_43_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_43.3' id='input_22_43_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_22_43_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_22_43_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_43.4' id='input_22_43_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_22_43_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_22_43_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_43.6' id='input_22_43_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_22_43_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_22_44\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Date of Birth<\/span><\/legend><div id='input_22_44' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_22_44_1_container'><label for='input_22_44_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_44[]' id='input_22_44_1'   aria-required='false'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_22_44_2_container'><label for='input_22_44_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_44[]' id='input_22_44_2'   aria-required='false'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_22_44_3_container'><label for='input_22_44_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_44[]' id='input_22_44_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_22_45\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Source of Income<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_22_45'><div class='gchoice gchoice_22_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='Social Security'  id='choice_22_45_1'   aria-describedby=\"gfield_description_22_45\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_22_45_1' id='label_22_45_1' class='gform-field-label gform-field-label--type-inline'>Social Security<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='SSI'  id='choice_22_45_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_45_2' id='label_22_45_2' class='gform-field-label gform-field-label--type-inline'>SSI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_45_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.3' type='checkbox'  value='Cash Assistance'  id='choice_22_45_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_45_3' id='label_22_45_3' class='gform-field-label gform-field-label--type-inline'>Cash Assistance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_45_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.4' type='checkbox'  value='Wages'  id='choice_22_45_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_45_4' id='label_22_45_4' class='gform-field-label gform-field-label--type-inline'>Wages<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_45_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.5' type='checkbox'  value='Unemployment Compensation'  id='choice_22_45_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_45_5' id='label_22_45_5' class='gform-field-label gform-field-label--type-inline'>Unemployment Compensation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_45_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.6' type='checkbox'  value='Child Support'  id='choice_22_45_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_45_6' id='label_22_45_6' class='gform-field-label gform-field-label--type-inline'>Child Support<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_45_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.7' type='checkbox'  value='Pension'  id='choice_22_45_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_45_7' id='label_22_45_7' class='gform-field-label gform-field-label--type-inline'>Pension<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_45_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.8' type='checkbox'  value='Workers Compensation'  id='choice_22_45_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_45_8' id='label_22_45_8' class='gform-field-label gform-field-label--type-inline'>Workers Compensation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_45_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.9' type='checkbox'  value='Veterans Benefits'  id='choice_22_45_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_45_9' id='label_22_45_9' class='gform-field-label gform-field-label--type-inline'>Veterans Benefits<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_45_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.11' type='checkbox'  value='Investment Income (interest, CDs, stocks\/bonds)'  id='choice_22_45_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_45_11' id='label_22_45_11' class='gform-field-label gform-field-label--type-inline'>Investment Income (interest, CDs, stocks\/bonds)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_45_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.12' type='checkbox'  value='Other'  id='choice_22_45_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_45_12' id='label_22_45_12' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_22_45'>Check all that apply<\/div><\/fieldset><div id=\"field_22_46\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_46'><span class='gform-field-label__text'>Employer<\/span><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_46' id='input_22_46' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_22_47\" class=\"gfield gfield--type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_47'><span class='gform-field-label__text'>Montly Gross Income<\/span><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_47' id='input_22_47' type='text' step='any'   value='' class='medium'    placeholder='0000.00' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_22_47\" \/><\/div><div class='gfield_description' id='gfield_description_22_47'>Enter only numbers.<\/div><\/div><div id=\"field_22_48\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_22_49\" class=\"gfield gfield--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\"  ><h2>Household Member 5<\/h2><\/div><fieldset id=\"field_22_50\" class=\"gfield gfield--type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_22_50'>\n                            \n                            <span id='input_22_50_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_50.3' id='input_22_50_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_22_50_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_22_50_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_50.4' id='input_22_50_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_22_50_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_22_50_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_50.6' id='input_22_50_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_22_50_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_22_51\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Date of Birth<\/span><\/legend><div id='input_22_51' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_22_51_1_container'><label for='input_22_51_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_51[]' id='input_22_51_1'   aria-required='false'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_22_51_2_container'><label for='input_22_51_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_51[]' id='input_22_51_2'   aria-required='false'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_22_51_3_container'><label for='input_22_51_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_51[]' id='input_22_51_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_22_52\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Source of Income<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_22_52'><div class='gchoice gchoice_22_52_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.1' type='checkbox'  value='Social Security'  id='choice_22_52_1'   aria-describedby=\"gfield_description_22_52\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_22_52_1' id='label_22_52_1' class='gform-field-label gform-field-label--type-inline'>Social Security<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_52_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.2' type='checkbox'  value='SSI'  id='choice_22_52_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_52_2' id='label_22_52_2' class='gform-field-label gform-field-label--type-inline'>SSI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_52_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.3' type='checkbox'  value='Cash Assistance'  id='choice_22_52_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_52_3' id='label_22_52_3' class='gform-field-label gform-field-label--type-inline'>Cash Assistance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_52_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.4' type='checkbox'  value='Wages'  id='choice_22_52_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_52_4' id='label_22_52_4' class='gform-field-label gform-field-label--type-inline'>Wages<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_52_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.5' type='checkbox'  value='Unemployment Compensation'  id='choice_22_52_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_52_5' id='label_22_52_5' class='gform-field-label gform-field-label--type-inline'>Unemployment Compensation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_52_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.6' type='checkbox'  value='Child Support'  id='choice_22_52_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_52_6' id='label_22_52_6' class='gform-field-label gform-field-label--type-inline'>Child Support<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_52_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.7' type='checkbox'  value='Pension'  id='choice_22_52_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_52_7' id='label_22_52_7' class='gform-field-label gform-field-label--type-inline'>Pension<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_52_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.8' type='checkbox'  value='Workers Compensation'  id='choice_22_52_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_52_8' id='label_22_52_8' class='gform-field-label gform-field-label--type-inline'>Workers Compensation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_52_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.9' type='checkbox'  value='Veterans Benefits'  id='choice_22_52_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_52_9' id='label_22_52_9' class='gform-field-label gform-field-label--type-inline'>Veterans Benefits<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_52_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.11' type='checkbox'  value='Investment Income (interest, CDs, stocks\/bonds)'  id='choice_22_52_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_52_11' id='label_22_52_11' class='gform-field-label gform-field-label--type-inline'>Investment Income (interest, CDs, stocks\/bonds)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_52_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.12' type='checkbox'  value='Other'  id='choice_22_52_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_52_12' id='label_22_52_12' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_22_52'>Check all that apply<\/div><\/fieldset><div id=\"field_22_53\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_53'><span class='gform-field-label__text'>Employer<\/span><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_53' id='input_22_53' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_22_54\" class=\"gfield gfield--type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_54'><span class='gform-field-label__text'>Montly Gross Income<\/span><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_22_54' type='text' step='any'   value='' class='medium'    placeholder='0000.00' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_22_54\" \/><\/div><div class='gfield_description' id='gfield_description_22_54'>Enter only numbers.<\/div><\/div><div id=\"field_22_55\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_22_56\" class=\"gfield gfield--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\"  ><h2>Household Member 6<\/h2><\/div><fieldset id=\"field_22_57\" class=\"gfield gfield--type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_22_57'>\n                            \n                            <span id='input_22_57_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_57.3' id='input_22_57_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_22_57_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_22_57_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_57.4' id='input_22_57_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_22_57_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_22_57_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_57.6' id='input_22_57_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_22_57_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_22_58\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Date of Birth<\/span><\/legend><div id='input_22_58' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_22_58_1_container'><label for='input_22_58_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_58[]' id='input_22_58_1'   aria-required='false'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_22_58_2_container'><label for='input_22_58_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_58[]' id='input_22_58_2'   aria-required='false'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_22_58_3_container'><label for='input_22_58_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_58[]' id='input_22_58_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_22_59\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Source of Income<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_22_59'><div class='gchoice gchoice_22_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Social Security'  id='choice_22_59_1'   aria-describedby=\"gfield_description_22_59\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_22_59_1' id='label_22_59_1' class='gform-field-label gform-field-label--type-inline'>Social Security<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_59_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.2' type='checkbox'  value='SSI'  id='choice_22_59_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_59_2' id='label_22_59_2' class='gform-field-label gform-field-label--type-inline'>SSI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_59_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.3' type='checkbox'  value='Cash Assistance'  id='choice_22_59_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_59_3' id='label_22_59_3' class='gform-field-label gform-field-label--type-inline'>Cash Assistance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_59_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.4' type='checkbox'  value='Wages'  id='choice_22_59_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_59_4' id='label_22_59_4' class='gform-field-label gform-field-label--type-inline'>Wages<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_59_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.5' type='checkbox'  value='Unemployment Compensation'  id='choice_22_59_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_59_5' id='label_22_59_5' class='gform-field-label gform-field-label--type-inline'>Unemployment Compensation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_59_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.6' type='checkbox'  value='Child Support'  id='choice_22_59_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_59_6' id='label_22_59_6' class='gform-field-label gform-field-label--type-inline'>Child Support<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_59_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.7' type='checkbox'  value='Pension'  id='choice_22_59_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_59_7' id='label_22_59_7' class='gform-field-label gform-field-label--type-inline'>Pension<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_59_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.8' type='checkbox'  value='Workers Compensation'  id='choice_22_59_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_59_8' id='label_22_59_8' class='gform-field-label gform-field-label--type-inline'>Workers Compensation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_59_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.9' type='checkbox'  value='Veterans Benefits'  id='choice_22_59_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_59_9' id='label_22_59_9' class='gform-field-label gform-field-label--type-inline'>Veterans Benefits<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_59_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.11' type='checkbox'  value='Investment Income (interest, CDs, stocks\/bonds)'  id='choice_22_59_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_59_11' id='label_22_59_11' class='gform-field-label gform-field-label--type-inline'>Investment Income (interest, CDs, stocks\/bonds)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_59_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.12' type='checkbox'  value='Other'  id='choice_22_59_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_59_12' id='label_22_59_12' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_22_59'>Check all that apply<\/div><\/fieldset><div id=\"field_22_60\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_60'><span class='gform-field-label__text'>Employer<\/span><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_60' id='input_22_60' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_22_61\" class=\"gfield gfield--type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_61'><span class='gform-field-label__text'>Montly Gross Income<\/span><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_61' id='input_22_61' type='text' step='any'   value='' class='medium'    placeholder='0000.00' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_22_61\" \/><\/div><div class='gfield_description' id='gfield_description_22_61'>Enter only numbers.<\/div><\/div><div id=\"field_22_32\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_22_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you have a familial or close personal relationship to anyone who works at Reading Housing Authority?<\/span><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_22_31'>\n\t\t\t<div class='gchoice gchoice_22_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_22_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_31_0' id='label_22_31_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_22_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_22_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_31_1' id='label_22_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_22_33\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_33'><span class='gform-field-label__text'>Please identify the RHA employee\u2019s name and nature of relationship:<\/span><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_33' id='input_22_33' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_22_11\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Certification<\/h3><\/div><fieldset id=\"field_22_8\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>I agree<\/span><span class=\"gfield_required\"><span class=\"gfield_required 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