{"id":5562,"date":"2025-05-13T17:27:09","date_gmt":"2025-05-13T23:27:09","guid":{"rendered":"https:\/\/veteran-affairs-louisiana.local\/?page_id=5562"},"modified":"2025-07-07T09:33:34","modified_gmt":"2025-07-07T14:33:34","slug":"fondo-de-asistencia-para-familias-militares","status":"publish","type":"page","link":"https:\/\/vetaffairs.la.gov\/es\/fondo-de-asistencia-para-familias-militares","title":{"rendered":"Fondo de Asistencia para Familias Militares"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"5562\" class=\"elementor elementor-5562\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-09f0e0b e-flex e-con-boxed e-con e-parent\" data-id=\"09f0e0b\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0fcae54 elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile elementor-widget elementor-widget-text-editor\" data-id=\"0fcae54\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>El Fondo de Asistencia para Familias Militares (MFA, por sus siglas en ingl\u00e9s) ofrece apoyo financiero a los veteranos de Luisiana y sus familias que atraviesan dificultades econ\u00f3micas. Se aplican ciertos criterios. Para recibir fondos a trav\u00e9s del MFA, se debe presentar una solicitud completa al Departamento de Asuntos de Veteranos de Luisiana (LDVA, por sus siglas en ingl\u00e9s), incluyendo toda la documentaci\u00f3n requerida. El MFA puede pagar hasta $10,000.00 por solicitud, por cada orden de servicio activo en un per\u00edodo de doce meses.<\/p><p>MFA se financia con donaciones privadas de particulares y empresas. Visite nuestra p\u00e1gina \u00abC\u00f3mo ayudar\u00bb para donar al fondo de MFA.<\/p><p><strong>Cualificaciones:<\/strong> Para optar a la ayuda del Fondo MFA, los veteranos y militares en servicio activo deben cumplir ciertos requisitos m\u00ednimos de servicio activo y haber sido dados de baja con honores. Los familiares directos de los veteranos y militares en servicio activo que re\u00fanan los requisitos tambi\u00e9n pueden optar a ella. Las solicitudes completas deben incluir toda la documentaci\u00f3n justificativa solicitada en el formulario.<\/p><p>Para obtener m\u00e1s informaci\u00f3n, puede llamar al n\u00famero gratuito <a href=\"tel:18774328982\">1-877-432-8982<\/a>.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b52bd99 elementor-widget elementor-widget-text-editor\" data-id=\"b52bd99\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>El Fondo de Asistencia para Familias Militares (MFA, por sus siglas en ingl\u00e9s) brinda ayuda financiera a veteranos de Luisiana y miembros de la Guardia Nacional o las Reservas de Luisiana que cumplan con los requisitos de elegibilidad. La Junta del MFA puede aprobar asistencia por un monto de hasta $10,000 para una solicitud basada en la necesidad en un per\u00edodo de 12 meses.<\/p><p>Un veterano de las Fuerzas Armadas con baja honorable o en condiciones honorables, o un miembro activo de la Guardia Nacional de Luisiana (LANG) o de la Reserva en buen estado con su unidad, que resida actualmente en Luisiana, puede recibir asistencia. El Fondo de Asistencia para Familias Militares cubre gastos de vivienda, servicios p\u00fablicos, algunos servicios m\u00e9dicos y otros gastos esenciales que generan dificultades econ\u00f3micas para el veterano o el miembro de la LANG o de la Reserva.<\/p><p>Un veterano de Luisiana o un miembro actual de la Guardia Nacional o las Reservas de Luisiana puede presentar una solicitud en l\u00ednea o\u00a0<a href=\"\/wp-content\/uploads\/2021\/09\/MFAApplication.pdf\" target=\"_blank\" rel=\"noopener\">Complete una solicitud en PDF rellenable<\/a> y enviar por correo electr\u00f3nico a <a href=\"mailto:holly.talley@la.gov\">holly.talley@la.gov <\/a>o por fax al (225) 219-5590, o por correo a Louisiana Department of Veterans Affairs, ATTN: MFA Administrator, PO Box 94095, Baton Rouge, LA 70804-9095. Los solicitantes tambi\u00e9n pueden solicitar que se les env\u00ede una solicitud por correo electr\u00f3nico a la direcci\u00f3n indicada anteriormente o llamando al (225) 219-5590. <a href=\"tel:2252193700\">(225) 219-3700<\/a>.<\/p><p>Nota: Para procesar todas las solicitudes con la mayor eficiencia posible, aseg\u00farese de enviar una solicitud completa con todos los documentos requeridos. Los fondos no est\u00e1n disponibles de inmediato tras la presentaci\u00f3n de la solicitud, ya que todas son revisadas por la Junta del Fondo de Asistencia para Familias Militares en su reuni\u00f3n mensual.<\/p><p>Las personas pueden apoyar a los veteranos de Luisiana y a los miembros actuales de la Guardia Nacional o de las Reservas de Luisiana haciendo una donaci\u00f3n:<\/p><ul><li><a href=\"\/es\/donar\/\">En l\u00ednea<\/a><\/li><li>Por correo a: Departamento de Asuntos de Veteranos de Luisiana<br \/>A la atenci\u00f3n del administrador del Ministerio de Asuntos Exteriores<br \/>Apartado de correos 94095<br \/>Baton Rouge, LA 70804-9095<\/li><li>En una declaraci\u00f3n de impuestos de Luisiana individual o corporativa<\/li><li>Al solicitar cualquier tipo de licencia en la Oficina de Veh\u00edculos Motorizados<\/li><li>Al comprar placas de matr\u00edcula de Apoyo a Nuestros Veteranos y Apoyo a Nuestras Tropas en la Oficina de Veh\u00edculos Motorizados<\/li><\/ul><p>Para obtener m\u00e1s informaci\u00f3n sobre el Fondo de Asistencia para Familias Militares o ayuda con una solicitud, llame al <a href=\"tel:2252193700\">(225) 219-3700<\/a> o correo electr\u00f3nico <a href=\"mailto:holly.talley@la.gov\">holly.talley@la.gov<\/a>.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6f2f74e elementor-widget elementor-widget-heading\" data-id=\"6f2f74e\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Solicitar financiaci\u00f3n para el MFA<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7d2559a mfa-form elementor-widget elementor-widget-shortcode\" data-id=\"7d2559a\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div 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   <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5' class='mfa-form' action='\/es\/wp-json\/wp\/v2\/pages\/5562#gf_5' data-formid='5' novalidate data-trp-original-action=\"\/es\/wp-json\/wp\/v2\/pages\/5562#gf_5\">\t\t\t\t\t<div style=\"display: none !important;\" class=\"akismet-fields-container gf_invisible\" data-prefix=\"ak_\">\n\t\t\t\t\t\t<label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label>\n\t\t\t\t\t\t<input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"107\" \/>\n\t\t\t\t\t\t<script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n\n\t\t\t\t\t<\/div><div class='gf_invisible ginput_recaptchav3'  data-tabindex='0'><input id=\"input_b996350b1bc3f639e62173210a79ccf2\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_b996350b1bc3f639e62173210a79ccf2\" value=\"\"\/><\/div>\n        <div id='gf_progressbar_wrapper_5' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Paso <span class='gf_step_current_page'>1<\/span> de <span class='gf_step_page_count'>7<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_14' style='width:14%;'><span>14%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_5_1' class='gform_page' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_124\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full sub-text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Nota: Si prefiere no presentar su solicitud en l\u00ednea, descargue el formulario. <a href=\"\/wp-content\/uploads\/2021\/09\/MFAApplication.pdf\" target=\"_blank\">Aplicaci\u00f3n PDF rellenable<\/a> aqu\u00ed.<\/p><\/div><fieldset id=\"field_5_1\" class=\"gfield gfield--type-name gfield--input-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' >Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/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_5_1'>\n                            \n                            <span id='input_5_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_5_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                    <label for='input_5_1_3' class='gform-field-label gform-field-label--type-sub'>Primero<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_5_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                    <label for='input_5_1_6' class='gform-field-label gform-field-label--type-sub'>\u00daltimo<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_3\" class=\"gfield gfield--type-select gfield--input-type-select 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_5_3'>Relaci\u00f3n con los veteranos<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_3' id='input_5_3' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccionar relaci\u00f3n<\/option><option value='Veteran' >Veterano<\/option><option value='Spouse' >C\u00f3nyuge<\/option><option value='Child' >Ni\u00f1o<\/option><option value='Other' >Otro<\/option><\/select><\/div><\/div><div id=\"field_5_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_4'>Otro<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_5_4' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_8\" class=\"gfield gfield--type-address gfield--input-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' >DIRECCI\u00d3N<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_8' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_8_1_container' >\n                                        <input type='text' name='input_8.1' id='input_5_8_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                        <label for='input_5_8_1' id='input_5_8_1_label' class='gform-field-label gform-field-label--type-sub'>Direcci\u00f3n postal<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_8_3_container' >\n                                    <input type='text' name='input_8.3' id='input_5_8_3' value=''    aria-required='true'   autocomplete=\"address-level2\" \/>\n                                    <label for='input_5_8_3' id='input_5_8_3_label' class='gform-field-label gform-field-label--type-sub'>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_8_4_container' >\n                                        <select name='input_8.4' id='input_5_8_4'     aria-required='true'   autocomplete=\"address-level1\" ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >Distrito de Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawai<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' selected='selected'>Luisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Misisip\u00ed<\/option><option value='Missouri' >Misuri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >Nuevo Hampshire<\/option><option value='New Jersey' >Nueva Jersey<\/option><option value='New Mexico' >Nuevo M\u00e9jico<\/option><option value='New York' >Nueva York<\/option><option value='North Carolina' >Carolina del Norte<\/option><option value='North Dakota' >Dakota del Norte<\/option><option value='Northern Mariana Islands' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oreg\u00f3n<\/option><option value='Pennsylvania' >Pensilvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >Carolina del Sur<\/option><option value='South Dakota' >Dakota del Sur<\/option><option value='Tennessee' >Tennesse<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >Virginia Occidental<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Fuerzas Armadas de las Am\u00e9ricas<\/option><option value='Armed Forces Europe' >Fuerzas Armadas de Europa<\/option><option value='Armed Forces Pacific' >Fuerzas Armadas del Pac\u00edfico<\/option><\/select>\n                                        <label for='input_5_8_4' id='input_5_8_4_label' class='gform-field-label gform-field-label--type-sub'>Estado<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_8_5_container' >\n                                    <input type='text' name='input_8.5' id='input_5_8_5' value=''    aria-required='true'   autocomplete=\"postal-code\" \/>\n                                    <label for='input_5_8_5' id='input_5_8_5_label' class='gform-field-label gform-field-label--type-sub'>C\u00f3digo postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_8.6' id='input_5_8_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_7\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_7'>Por favor seleccione su parroquia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_5_7' class='large gfield_select'  aria-describedby=\"gfield_description_5_7\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione Parroquia<\/option><option value='Acadia' >Acadia<\/option><option value='Allen' >Allen<\/option><option value='Ascension' >Ascensi\u00f3n<\/option><option value='Assumption' >Suposici\u00f3n<\/option><option value='Avoyelles' >Avoyelles<\/option><option value='Beauregard' >Beauregard<\/option><option value='Bienville' >Bienville<\/option><option value='Bossier' >M\u00e1s mand\u00f3n<\/option><option value='Caddo' >Caddo<\/option><option value='Calcasieu' >Calcasieu<\/option><option value='Caldwell' >Caldwell<\/option><option value='Cameron' >Cameron<\/option><option value='Catahoula' >Catahoula<\/option><option value='Claiborne' >Claiborne<\/option><option value='Concordia' >Concordia<\/option><option value='De Soto' >De Soto<\/option><option value='East Baton Rouge' >East Baton Rouge<\/option><option value='East Carroll' >Carroll Este<\/option><option value='East Feliciana' >Feliciana del Este<\/option><option value='Evangeline' >Evangelina<\/option><option value='Franklin' >Franklin<\/option><option value='Grant' >Conceder<\/option><option value='Iberia' >Iberia<\/option><option value='Iberville' >Iberville<\/option><option value='Jackson' >Jackson<\/option><option value='Jefferson' >Jefferson<\/option><option value='Jefferson Davis' >Jefferson Davis<\/option><option value='La Salle' >La Salle<\/option><option value='Lafayette' >Lafayette<\/option><option value='Lafourche' >Lafourche<\/option><option value='Lincoln' >Lincoln<\/option><option value='Livingston' >Livingston<\/option><option value='Madison' >Madison<\/option><option value='Morehouse' >Morehouse<\/option><option value='Natchitoches' >Natchitoches<\/option><option value='Orleans' >Orleans<\/option><option value='Ouachita' >Ouachita<\/option><option value='Plaquemines' >Plaqueminas<\/option><option value='Pointe Coupee' >Pointe Coup\u00e9e<\/option><option value='Rapides' >R\u00e1pidos<\/option><option value='Red River' >R\u00edo Rojo<\/option><option value='Richland' >Richland<\/option><option value='Sabine' >Sabino<\/option><option value='St. Bernard' >San Bernardo<\/option><option value='St. Charles' >San Carlos<\/option><option value='St. Helena' >Santa Elena<\/option><option value='St. James' >Santiago<\/option><option value='St. John The Baptist' >San Juan Bautista<\/option><option value='St. Landry' >San Landry<\/option><option value='St. Martin' >San Mart\u00edn<\/option><option value='St. Mary' >Santa Mar\u00eda<\/option><option value='St. Tammany' >San Tammany<\/option><option value='Tangipahoa' >Tangipahoa<\/option><option value='Tensas' >Tensas<\/option><option value='Terrebonne' >Terrebonne<\/option><option value='Union' >Uni\u00f3n<\/option><option value='Vermilion' >Bermell\u00f3n<\/option><option value='Vernon' >Vernon<\/option><option value='Washington' >Washington<\/option><option value='Webster' >Webster<\/option><option value='West Baton Rouge' >Oeste de Baton Rouge<\/option><option value='West Carroll' >West Carroll<\/option><option value='West Feliciana' >Feliciana del Oeste<\/option><option value='Winn' >Ganar<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_5_7'>Por favor seleccione la parroquia donde reside actualmente de la lista anterior.<\/div><\/div><div id=\"field_5_9\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full 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_5_9'>Correo electr\u00f3nico<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_9' id='input_5_9' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_5_9\" autocomplete=\"email\"\/>\n                        <\/div><div class='gfield_description' id='gfield_description_5_9'>Formato: usuario@dominio.com<\/div><\/div><div id=\"field_5_10\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_5_10'>Tel\u00e9fono m\u00f3vil<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_5_10' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_5_10\" autocomplete=\"tel\" \/><\/div><div class='gfield_description' id='gfield_description_5_10'>Formato: (123) 456-7890<\/div><\/div><div id=\"field_5_11\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_11'>Tel\u00e9fono fijo<\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_5_11' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_5_11\"  \/><\/div><div class='gfield_description' id='gfield_description_5_11'>Formato: (123) 456-7890<\/div><\/div><div id=\"field_5_12\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_12'>Tel\u00e9fono del trabajo<\/label><div class='ginput_container ginput_container_phone'><input name='input_12' id='input_5_12' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_5_12\"  \/><\/div><div class='gfield_description' id='gfield_description_5_12'>Formato: (123) 456-7890<\/div><\/div><div id=\"field_5_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_13'>Estado civil<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_5_13' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_14\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_14'>Licencia de matrimonio<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='134217728' \/><input name='input_14' id='input_5_14' type='file' class='large' aria-describedby=\"gfield_upload_rules_5_14\" onchange='javascript:gformValidateFileSize( this, 134217728 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_14'>Tama\u00f1o m\u00e1ximo de archivo: 128 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_5_14'><\/div> <\/div><\/div><div id=\"field_5_15\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_15'>Certificado de nacimiento o poder notarial<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='134217728' \/><input name='input_15' id='input_5_15' type='file' class='large' aria-describedby=\"gfield_upload_rules_5_15\" onchange='javascript:gformValidateFileSize( this, 134217728 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_15'>Tama\u00f1o m\u00e1ximo de archivo: 128 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_5_15'><\/div> <\/div><\/div><div id=\"field_5_16\" class=\"gfield gfield--type-number gfield--input-type-number 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_5_16'>N\u00famero de dependientes\/hijos en el hogar<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_16' id='input_5_16' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_17\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload 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_5_17'>Identificaci\u00f3n con foto de veterano<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='134217728' \/><input name='input_17' id='input_5_17' type='file' class='large' aria-describedby=\"gfield_upload_rules_5_17\" onchange='javascript:gformValidateFileSize( this, 134217728 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_17'>Tama\u00f1o m\u00e1ximo de archivo: 128 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_5_17'><\/div> <\/div><\/div><div id=\"field_5_18\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_5_18'>C\u00f3nyuge u otras personas mayores de 18 a\u00f1os: identificaci\u00f3n con foto<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_5_18' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_5_18&quot;,&quot;container&quot;:&quot;gform_multifile_upload_5_18&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_5_18&quot;,&quot;filelist&quot;:&quot;gform_preview_5_18&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/?gf_page=3e476ed529d9fa4&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;134217728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:5,&quot;field_id&quot;:18,&quot;_gform_file_upload_nonce_5_18&quot;:&quot;71b5f58931&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_5_18&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_5_18' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Suelte los archivos aqu\u00ed o <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_5_18' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_5_18\"  >Seleccionar archivos<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_18'>Tama\u00f1o m\u00e1ximo de archivo: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_18'><\/ul> <div id='gform_preview_5_18' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_42\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto al visualizar el formulario.\"><\/i><span>Este campo est\u00e1 oculto al visualizar el formulario.<\/span><\/div><label class='gfield_label gform-field-label' for='input_5_42'>Edades de los ni\u00f1os<\/label><div class='ginput_container ginput_container_number'><input name='input_42' id='input_5_42' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_43\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto al visualizar el formulario.\"><\/i><span>Este campo est\u00e1 oculto al visualizar el formulario.<\/span><\/div><label class='gfield_label gform-field-label' for='input_5_43'>\u00bfNecesidades especiales?<\/label><div class='ginput_container ginput_container_number'><input name='input_43' id='input_5_43' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_147\" class=\"gfield gfield--type-text gfield--input-type-text 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_5_147'>Edades de los ni\u00f1os<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_147' id='input_5_147' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_148\" class=\"gfield gfield--type-text gfield--input-type-text 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_5_148'>Necesidades especiales<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_148' id='input_5_148' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_5_132' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Pr\u00f3ximo'  \/> <button type='button'  id='gform_save_5_2_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> GUARDAR Y CONTINUAR M\u00c1S TARDE<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_2' class='gform_page' data-js='page-field-id-132' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_140\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Informaci\u00f3n de contacto de veteranos\/miembros del servicio militar<\/h3><div class='gsection_description' id='gfield_description_5_140'>Esta informaci\u00f3n es solo para el veterano si \u00e9l\/ella no es el solicitante.<\/div><\/div><div id=\"field_5_23\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_23'>Direcci\u00f3n de correo electr\u00f3nico<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_23' id='input_5_23' type='email' value='' class='large'     aria-invalid=\"false\" aria-describedby=\"gfield_description_5_23\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_5_23'>Formato: usuario@dominio.com<\/div><\/div><div id=\"field_5_24\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_24'>Tel\u00e9fono fijo<\/label><div class='ginput_container ginput_container_phone'><input name='input_24' id='input_5_24' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_5_24\"  \/><\/div><div class='gfield_description' id='gfield_description_5_24'>Formato: (123) 456-7890<\/div><\/div><div id=\"field_5_25\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_25'>Tel\u00e9fono m\u00f3vil<\/label><div class='ginput_container ginput_container_phone'><input name='input_25' id='input_5_25' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_5_25\"  \/><\/div><div class='gfield_description' id='gfield_description_5_25'>Formato: (123) 456-7890<\/div><\/div><div id=\"field_5_26\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_26'>Tel\u00e9fono del trabajo<\/label><div class='ginput_container ginput_container_phone'><input name='input_26' id='input_5_26' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_5_26\"  \/><\/div><div class='gfield_description' id='gfield_description_5_26'>Formato: (123) 456-7890<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_133' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='button' id='gform_next_button_5_133' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Pr\u00f3ximo'  \/> <button type='button'  id='gform_save_5_3_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> GUARDAR Y CONTINUAR M\u00c1S TARDE<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_3' class='gform_page' data-js='page-field-id-133' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_141\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Informaci\u00f3n para veteranos\/miembros del servicio<\/h3><div class='gsection_description' id='gfield_description_5_141'>Tal como aparece en el formulario DD214 o en las \u00f3rdenes militares.<\/div><\/div><fieldset id=\"field_5_149\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Actualmente estoy sirviendo<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_149'>\n\t\t\t<div class='gchoice gchoice_5_149_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='Present'  id='choice_5_149_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_149_0' id='label_5_149_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_149_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='No'  id='choice_5_149_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_149_1' id='label_5_149_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_28\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload 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_5_28'>DD214 o alta<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='134217728' \/><input name='input_28' id='input_5_28' type='file' class='large' aria-describedby=\"gfield_upload_rules_5_28\" onchange='javascript:gformValidateFileSize( this, 134217728 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_28'>Tama\u00f1o m\u00e1ximo de archivo: 128 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_5_28'><\/div> <\/div><\/div><fieldset id=\"field_5_29\" class=\"gfield gfield--type-name gfield--input-type-name 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' >Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/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_5_29'>\n                            \n                            <span id='input_5_29_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_29.3' id='input_5_29_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_29_3' class='gform-field-label gform-field-label--type-sub'>Primero<\/label>\n                                                <\/span>\n                            <span id='input_5_29_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_29.4' id='input_5_29_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_29_4' class='gform-field-label gform-field-label--type-sub'>Medio<\/label>\n                                                <\/span>\n                            <span id='input_5_29_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_29.6' id='input_5_29_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_29_6' class='gform-field-label gform-field-label--type-sub'>\u00daltimo<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_5_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >\u00bfResidente actual de Los \u00c1ngeles?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_30'>\n\t\t\t<div class='gchoice gchoice_5_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_5_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_30_0' id='label_5_30_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_5_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_30_1' id='label_5_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_31\" class=\"gfield gfield--type-text gfield--input-type-text 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_5_31'>Rama de servicio<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_5_31' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_32\" class=\"gfield gfield--type-text gfield--input-type-text 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_5_32'>Rango<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_5_32' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_34\" class=\"gfield gfield--type-number gfield--input-type-number 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_5_34'>Total de a\u00f1os de servicio<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_34' id='input_5_34' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_35\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half 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_5_35'>Entr\u00f3 en servicio<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_35' id='input_5_35' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_5_35_date_format gfield_description_5_35\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_35_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_35' class='gform_hidden' value='https:\/\/vetaffairs.la.gov\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_5_35'>Formato: mm\/dd\/aaaa<\/div><\/div><div id=\"field_5_36\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half 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_5_36'>Sali\u00f3 del servicio<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_36' id='input_5_36' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_5_36_date_format gfield_description_5_36\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_36_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_36' class='gform_hidden' value='https:\/\/vetaffairs.la.gov\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_5_36'>Formato: mm\/dd\/aaaa<\/div><\/div><div id=\"field_5_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_37'>Unidad de asignaci\u00f3n (si est\u00e1 actualmente asignada)<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_5_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_41\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half 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_5_41'>Fecha de activaci\u00f3n (si est\u00e1 actualmente activado)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_41' id='input_5_41' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_5_41_date_format gfield_description_5_41\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_41_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_41' class='gform_hidden' value='https:\/\/vetaffairs.la.gov\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_5_41'>Formato: mm\/dd\/aaaa<\/div><\/div><fieldset id=\"field_5_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfActualmente eres miembro de la Guardia Nacional o de las Reservas de Luisiana?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_38'>\n\t\t\t<div class='gchoice gchoice_5_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Yes'  id='choice_5_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_38_0' id='label_5_38_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No'  id='choice_5_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_38_1' id='label_5_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_40\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload 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_5_40'>\u00d3rdenes militares<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='134217728' \/><input name='input_40' id='input_5_40' type='file' class='large' aria-describedby=\"gfield_upload_rules_5_40\" onchange='javascript:gformValidateFileSize( this, 134217728 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_40'>Tama\u00f1o m\u00e1ximo de archivo: 128 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_5_40'><\/div> <\/div><\/div><div id=\"field_5_166\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Punto de contacto de la unidad militar para la verificaci\u00f3n<\/h3><div class='gsection_description' id='gfield_description_5_166'>(Solo para miembros actuales de la Guardia Nacional\/Reserva\/Servicio Activo)<\/div><\/div><div id=\"field_5_167\" class=\"gfield gfield--type-text gfield--input-type-text 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_5_167'>Nombre de la unidad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_167' id='input_5_167' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_168\" class=\"gfield gfield--type-text gfield--input-type-text 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_5_168'>Rango\/T\u00edtulo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_168' id='input_5_168' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_169\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half 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_5_169'>Direcci\u00f3n de correo electr\u00f3nico de contacto de la unidad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_169' id='input_5_169' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_5_169\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_5_169'>Formato: usuario@dominio.com<\/div><\/div><div id=\"field_5_170\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_5_170'>N\u00famero de tel\u00e9fono de contacto de la unidad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_170' id='input_5_170' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_171\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_5_171'>N\u00famero de fax de contacto de la unidad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_171' id='input_5_171' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_174\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><div class='gsection_description' id='gfield_description_5_174'>Certifico que la informaci\u00f3n proporcionada en esta solicitud es veraz y correcta seg\u00fan mi leal saber y entender. Entiendo que no hay garant\u00eda de que mi solicitud sea aprobada. Asimismo, entiendo que, si mi solicitud es aprobada, la ayuda, en la mayor\u00eda de los casos, se pagar\u00e1 directamente al proveedor del servicio y no a m\u00ed.<\/div><\/div><div id=\"field_5_172\" class=\"gfield gfield--type-signature gfield--input-type-signature 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_5_172'>Firma<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_5_172_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_5_172_valid' id='input_5_172_valid' \/><canvas id='input_5_172' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/vetaffairs.la.gov\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_5_172_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_5_172_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Firma clara' ><\/div><input type='hidden' id='input_5_172_data' name='input_5_172_data' value=''><\/div><\/div><div id=\"field_5_173\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half 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_5_173'>Fecha<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_173' id='input_5_173' type='text' value='04\/04\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_5_173_date_format gfield_description_5_173\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_173_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_173' class='gform_hidden' value='https:\/\/vetaffairs.la.gov\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_5_173'>Formato: mm\/dd\/aaaa<\/div><\/div><div id=\"field_5_47\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full please-section gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Por favor, complete este formulario en su totalidad. La informaci\u00f3n se utilizar\u00e1 para evaluar nuestra capacidad de ayudarle.<\/p><\/div><div id=\"field_5_49\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_5_49'>Por favor, explique: \u00bfCu\u00e1nto necesita exactamente? \u00bfPor qu\u00e9 necesita ayuda? Indique todas las dem\u00e1s fuentes de asistencia, como seguros y programas militares, a las que haya solicitado ayuda. Si es necesario, adjunte documentaci\u00f3n adicional.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_49' id='input_5_49' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_50\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-half mfa-form-list-left gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><b>Ejemplos de gastos admisibles:<\/b><\/p>\n<ul>\n<li>Gastos del hogar: Hipoteca, alquiler y algunas reparaciones de la vivienda principal.<\/li>\n<li>Servicios p\u00fablicos: Electricidad, gas, agua, alcantarillado y recogida de basuras.<\/li>\n<li>Gastos del veh\u00edculo: Pagos, seguro y algunas reparaciones importantes.<\/li>\n<li>Comida y ropa<\/li>\n<li>Se pueden considerar algunos gastos m\u00e9dicos.<\/li>\n<li>Gastos considerados una necesidad b\u00e1sica para la vida que generan una dificultad financiera excesiva.<\/li>\n<\/ul><\/div><div id=\"field_5_51\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-half mfa-form-list-right gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><b>Ejemplos de gastos NO elegibles:<\/b><\/p>\n<ul>\n<li>Compra o mejora de viviendas<\/li>\n<li>Gastos o reparaciones de la propiedad de renta<\/li>\n<li>Facturas de tarjetas de cr\u00e9dito o tarjetas de cargo militares<\/li>\n<li>Pago de multas o gastos legales.<\/li>\n<li>Financiaci\u00f3n de permisos o vacaciones.<\/li>\n<li>Tel\u00e9fonos por cable, internet o tel\u00e9fonos secundarios<\/li>\n<li>Procedimientos m\u00e9dicos cosm\u00e9ticos o experimentales y sus gastos.<\/li>\n<li>Impuestos - sobre la propiedad o de otro tipo<\/li>\n<li>Art\u00edculos no esenciales para las necesidades b\u00e1sicas de la vida.<\/li>\n<\/ul><\/div><div id=\"field_5_52\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full blue-background gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Los gastos admisibles y no admisibles que se enumeran no son exhaustivos. Todas las solicitudes se revisan individualmente. El administrador, el comit\u00e9 y la junta directiva de la MFA se reservan el derecho de hacer excepciones seg\u00fan cada caso. Cada solicitud se revisar\u00e1 cuidadosamente seg\u00fan sus propios m\u00e9ritos.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_134' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='button' id='gform_next_button_5_134' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Pr\u00f3ximo'  \/> <button type='button'  id='gform_save_5_4_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> GUARDAR Y CONTINUAR M\u00c1S TARDE<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_4' class='gform_page' data-js='page-field-id-134' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_142\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><div class='gsection_description' id='gfield_description_5_142'>Enumere todas las que correspondan <br\/> <br\/>\n<strong>Importante:<\/strong> Debe incluir TODOS los ingresos mensuales recurrentes del hogar de TODOS los miembros del hogar (veterano\/miembro del servicio militar, c\u00f3nyuge, etc.). Incluya comprobantes de ingresos; por ejemplo, los dos \u00faltimos recibos de pago, la carta de concesi\u00f3n de beneficios de la VA m\u00e1s reciente, la carta de beneficios del Seguro Social del a\u00f1o en curso, etc.<\/div><\/div><div id=\"field_5_160\" class=\"gfield gfield--type-section gfield--input-type-section gsection h4-style field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Ingresos mensuales ($)<\/h3><\/div><div id=\"field_5_59\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half number-field 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_5_59'>Veterano<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_59' id='input_5_59' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_59\" \/><div class='gfield_description instruction' id='gfield_instruction_5_59'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_5_157\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-half number-field field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >C\u00f3nyuge\/Miembros del hogar mayores de 18 a\u00f1os<\/legend><div class='ginput_container ginput_container_list ginput_list'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_157_cell1 gform-grid-col' ><input aria-invalid='false'  aria-describedby=\"gfield_description_5_157\" aria-label='C\u00f3nyuge\/Miembros del hogar mayores de 18 a\u00f1os, fila 1' data-aria-label-template='Spouse\/Household Members 18+, Row {0}' type='text' name='input_157[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item' aria-label='A\u00f1ade otra fila' onclick='gformAddListItem(this, 0)'>Agregar<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_157'>Si corresponde<\/div><\/fieldset><div id=\"field_5_161\" class=\"gfield gfield--type-section gfield--input-type-section gsection h4-style field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Salario militar mensual ($) (si corresponde)<\/h3><\/div><div id=\"field_5_62\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half number-field 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_5_62'>Veterano<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_62' id='input_5_62' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_62\" \/><div class='gfield_description instruction' id='gfield_instruction_5_62'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_5_156\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-half number-field field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >C\u00f3nyuge\/Miembros del hogar mayores de 18 a\u00f1os<\/legend><div class='ginput_container ginput_container_list ginput_list'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_156_cell1 gform-grid-col' ><input aria-invalid='false'  aria-describedby=\"gfield_description_5_156\" aria-label='C\u00f3nyuge\/Miembros del hogar mayores de 18 a\u00f1os, fila 1' data-aria-label-template='Spouse\/Household Members 18+, Row {0}' type='text' name='input_156[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item' aria-label='A\u00f1ade otra fila' onclick='gformAddListItem(this, 0)'>Agregar<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_156'>Si corresponde<\/div><\/fieldset><div id=\"field_5_162\" class=\"gfield gfield--type-section gfield--input-type-section gsection h4-style field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Ingresos\/Discapacidad del Seguro Social ($)<\/h3><\/div><div id=\"field_5_65\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half number-field 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_5_65'>Veterano<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_65' id='input_5_65' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_65\" \/><div class='gfield_description instruction' id='gfield_instruction_5_65'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_5_155\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-half number-field field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >C\u00f3nyuge\/Miembros del hogar mayores de 18 a\u00f1os<\/legend><div class='ginput_container ginput_container_list ginput_list'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_155_cell1 gform-grid-col' ><input aria-invalid='false'  aria-describedby=\"gfield_description_5_155\" aria-label='C\u00f3nyuge\/Miembros del hogar mayores de 18 a\u00f1os, fila 1' data-aria-label-template='Spouse\/Household Members 18+, Row {0}' type='text' name='input_155[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item' aria-label='A\u00f1ade otra fila' onclick='gformAddListItem(this, 0)'>Agregar<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_155'>Si corresponde<\/div><\/fieldset><div id=\"field_5_163\" class=\"gfield gfield--type-section gfield--input-type-section gsection h4-style field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Pensi\u00f3n de VA u otros beneficios de VA ($)<\/h3><\/div><div id=\"field_5_68\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half number-field 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_5_68'>Veterano<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_68' id='input_5_68' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_68\" \/><div class='gfield_description instruction' id='gfield_instruction_5_68'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_5_154\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-half number-field field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >C\u00f3nyuge\/Miembros del hogar mayores de 18 a\u00f1os<\/legend><div class='ginput_container ginput_container_list ginput_list'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_154_cell1 gform-grid-col' ><input aria-invalid='false'  aria-describedby=\"gfield_description_5_154\" aria-label='C\u00f3nyuge\/Miembros del hogar mayores de 18 a\u00f1os, fila 1' data-aria-label-template='Spouse\/Household Members 18+, Row {0}' type='text' name='input_154[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item' aria-label='A\u00f1ade otra fila' onclick='gformAddListItem(this, 0)'>Agregar<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_154'>Si corresponde<\/div><\/fieldset><div id=\"field_5_164\" class=\"gfield gfield--type-section gfield--input-type-section gsection h4-style field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Ingresos de jubilaci\u00f3n ($)<\/h3><\/div><div id=\"field_5_71\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half number-field 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_5_71'>Veterano<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_71' id='input_5_71' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_71\" \/><div class='gfield_description instruction' id='gfield_instruction_5_71'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_5_153\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-half number-field field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >C\u00f3nyuge\/Miembros del hogar mayores de 18 a\u00f1os<\/legend><div class='ginput_container ginput_container_list ginput_list'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_153_cell1 gform-grid-col' ><input aria-invalid='false'  aria-describedby=\"gfield_description_5_153\" aria-label='C\u00f3nyuge\/Miembros del hogar mayores de 18 a\u00f1os, fila 1' data-aria-label-template='Spouse\/Household Members 18+, Row {0}' type='text' name='input_153[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item' aria-label='A\u00f1ade otra fila' onclick='gformAddListItem(this, 0)'>Agregar<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_153'>Si corresponde<\/div><\/fieldset><div id=\"field_5_165\" class=\"gfield gfield--type-section gfield--input-type-section gsection h4-style field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Asistencia p\u00fablica (SNAP, etc.) ($)<\/h3><\/div><div id=\"field_5_130\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half number-field 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_5_130'>Veterano<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_130' id='input_5_130' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_130\" \/><div class='gfield_description instruction' id='gfield_instruction_5_130'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_5_151\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-half number-field field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >C\u00f3nyuge\/Miembros del hogar mayores de 18 a\u00f1os<\/legend><div class='ginput_container ginput_container_list ginput_list'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_151_cell1 gform-grid-col' ><input aria-invalid='false'  aria-describedby=\"gfield_description_5_151\" aria-label='C\u00f3nyuge\/Miembros del hogar mayores de 18 a\u00f1os, fila 1' data-aria-label-template='Spouse\/Household Members 18+, Row {0}' type='text' name='input_151[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item' aria-label='A\u00f1ade otra fila' onclick='gformAddListItem(this, 0)'>Agregar<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_151'>Si corresponde<\/div><\/fieldset><div id=\"field_5_150\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_150'>Otros ingresos<\/label><div class='ginput_container ginput_container_text'><input name='input_150' id='input_5_150' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_77\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_77'>Veterano<\/label><div class='ginput_container ginput_container_number'><input name='input_77' id='input_5_77' type='text' step='any' min='0'  value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_77\" \/><div class='gfield_description instruction' id='gfield_instruction_5_77'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_5_152\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-third number-field field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >C\u00f3nyuge\/Miembros del hogar mayores de 18 a\u00f1os<\/legend><div class='ginput_container ginput_container_list ginput_list'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_152_cell1 gform-grid-col' ><input aria-invalid='false'  aria-describedby=\"gfield_description_5_152\" aria-label='C\u00f3nyuge\/Miembros del hogar mayores de 18 a\u00f1os, fila 1' data-aria-label-template='Spouse\/Household Members 18+, Row {0}' type='text' name='input_152[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item' aria-label='A\u00f1ade otra fila' onclick='gformAddListItem(this, 0)'>Agregar<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_152'>Si corresponde<\/div><\/fieldset><div id=\"field_5_74\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full number-field 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_5_74'>Ingreso total del hogar<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_74' id='input_5_74' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_74\" \/><div class='gfield_description instruction' id='gfield_instruction_5_74'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_135' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='button' id='gform_next_button_5_135' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Pr\u00f3ximo'  \/> <button type='button'  id='gform_save_5_5_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> GUARDAR Y CONTINUAR M\u00c1S TARDE<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_5' class='gform_page' data-js='page-field-id-135' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_143\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Gastos mensuales promedio de un hogar<\/h3><\/div><div id=\"field_5_80\" class=\"gfield gfield--type-number gfield--input-type-number 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_5_80'>Hipoteca\/Alquiler<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_80' id='input_5_80' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_80\" \/><div class='gfield_description instruction' id='gfield_instruction_5_80'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><div id=\"field_5_81\" class=\"gfield gfield--type-number gfield--input-type-number 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_5_81'>Electricidad \/ Gas<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_81' id='input_5_81' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_81\" \/><div class='gfield_description instruction' id='gfield_instruction_5_81'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><div id=\"field_5_82\" class=\"gfield gfield--type-number gfield--input-type-number 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_5_82'>Agua, aguas residuales, basura<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_82' id='input_5_82' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_82\" \/><div class='gfield_description instruction' id='gfield_instruction_5_82'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><div id=\"field_5_85\" class=\"gfield gfield--type-number gfield--input-type-number 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_5_85'>Comida\/Ropa<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_85' id='input_5_85' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_85\" \/><div class='gfield_description instruction' id='gfield_instruction_5_85'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><div id=\"field_5_84\" class=\"gfield gfield--type-number gfield--input-type-number 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_5_84'>Pago(s) del veh\u00edculo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_84' id='input_5_84' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_84\" \/><div class='gfield_description instruction' id='gfield_instruction_5_84'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><div id=\"field_5_83\" class=\"gfield gfield--type-number gfield--input-type-number 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_5_83'>Seguro<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_83' id='input_5_83' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_83\" \/><div class='gfield_description instruction' id='gfield_instruction_5_83'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_5_158\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full assistance-field gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Asistencia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Otros gastos\/gastos varios, si procede<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Importe, si procede<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Descripci\u00f3n<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_158_cell1 gform-grid-col' data-label='Other\/Miscellaneous Expenses, if applicable'><input aria-invalid='false' aria-required=\"true\"  aria-label='Otros gastos\/gastos varios, si corresponde, fila 1' data-aria-label-template='Other\/Miscellaneous Expenses, if applicable, Row {0}' type='text' name='input_158[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_158_cell2 gform-grid-col' data-label='Amount, if applicable'><input aria-invalid='false' aria-required=\"true\"  aria-label='Importe, si procede, fila 1' data-aria-label-template='Amount, if applicable, Row {0}' type='text' name='input_158[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_158_cell3 gform-grid-col' data-label='Description'><input aria-invalid='false' aria-required=\"true\"  aria-label='Descripci\u00f3n, Fila 1' data-aria-label-template='Description, Row {0}' type='text' name='input_158[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item' aria-label='A\u00f1ade otra fila' onclick='gformAddListItem(this, 0)'>Agregar<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_5_88\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full number-field 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_5_88'>Gastos totales del hogar<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_88' id='input_5_88' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_88\" \/><div class='gfield_description instruction' id='gfield_instruction_5_88'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_136' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='button' id='gform_next_button_5_136' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Pr\u00f3ximo'  \/> <button type='button'  id='gform_save_5_6_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> GUARDAR Y CONTINUAR M\u00c1S TARDE<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_6' class='gform_page' data-js='page-field-id-136' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_144\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Gastos y cantidad solicitada<\/h3><div class='gsection_description' id='gfield_description_5_144'>Indique el importe total adeudado de cada una de las facturas para cuyo pago solicita ayuda. Se requiere documentaci\u00f3n que respalde los importes solicitados. Esta documentaci\u00f3n incluye, entre otros: copias de la hipoteca\/contrato de arrendamiento, facturas, recibos, presupuestos de reparaci\u00f3n, avisos de cancelaci\u00f3n, notificaciones de desalojo\/ejecuci\u00f3n hipotecaria\/recuperaci\u00f3n de posesi\u00f3n o cualquier otro documento similar. No se considerar\u00e1n las solicitudes de ayuda que no incluyan toda la documentaci\u00f3n requerida.<\/div><\/div><div id=\"field_5_91\" class=\"gfield gfield--type-number gfield--input-type-number 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_5_91'>Hipoteca\/Alquiler<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_91' id='input_5_91' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_91\" \/><div class='gfield_description instruction' id='gfield_instruction_5_91'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><div id=\"field_5_92\" class=\"gfield gfield--type-number gfield--input-type-number 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_5_92'>Servicios p\u00fablicos: electricidad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_92' id='input_5_92' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_92\" \/><div class='gfield_description instruction' id='gfield_instruction_5_92'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><div id=\"field_5_93\" class=\"gfield gfield--type-number gfield--input-type-number 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_5_93'>Servicios p\u00fablicos: Agua, alcantarillado, basura<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_93' id='input_5_93' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_93\" \/><div class='gfield_description instruction' id='gfield_instruction_5_93'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><div id=\"field_5_103\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload 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='gform_browse_button_5_103'>Extracto hipotecario; o informaci\u00f3n completa del contrato de arrendamiento y del propietario.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_5_103' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_5_103&quot;,&quot;container&quot;:&quot;gform_multifile_upload_5_103&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_5_103&quot;,&quot;filelist&quot;:&quot;gform_preview_5_103&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/?gf_page=3e476ed529d9fa4&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;134217728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:5,&quot;field_id&quot;:103,&quot;_gform_file_upload_nonce_5_103&quot;:&quot;09de59ed57&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_5_103&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_5_103' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Suelte los archivos aqu\u00ed o <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_5_103' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_5_103\"  >Seleccionar archivos<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_103'>Tama\u00f1o m\u00e1ximo de archivo: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_103'><\/ul> <div id='gform_preview_5_103' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_104\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload 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='gform_browse_button_5_104'>Factura de servicios p\u00fablicos m\u00e1s reciente\/actual<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_5_104' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_5_104&quot;,&quot;container&quot;:&quot;gform_multifile_upload_5_104&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_5_104&quot;,&quot;filelist&quot;:&quot;gform_preview_5_104&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/?gf_page=3e476ed529d9fa4&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;134217728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:5,&quot;field_id&quot;:104,&quot;_gform_file_upload_nonce_5_104&quot;:&quot;f54c9f02ae&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_5_104&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_5_104' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Suelte los archivos aqu\u00ed o <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_5_104' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_5_104\"  >Seleccionar archivos<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_104'>Tama\u00f1o m\u00e1ximo de archivo: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_104'><\/ul> <div id='gform_preview_5_104' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_105\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload 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='gform_browse_button_5_105'>Factura de servicios p\u00fablicos m\u00e1s reciente\/actual<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_5_105' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_5_105&quot;,&quot;container&quot;:&quot;gform_multifile_upload_5_105&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_5_105&quot;,&quot;filelist&quot;:&quot;gform_preview_5_105&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/?gf_page=3e476ed529d9fa4&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;134217728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:5,&quot;field_id&quot;:105,&quot;_gform_file_upload_nonce_5_105&quot;:&quot;918cc33198&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_5_105&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_5_105' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Suelte los archivos aqu\u00ed o <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_5_105' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_5_105\"  >Seleccionar archivos<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_105'>Tama\u00f1o m\u00e1ximo de archivo: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_105'><\/ul> <div id='gform_preview_5_105' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_96\" class=\"gfield gfield--type-number gfield--input-type-number 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_5_96'>Servicios p\u00fablicos: gas<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_96' id='input_5_96' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_96\" \/><div class='gfield_description instruction' id='gfield_instruction_5_96'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><div id=\"field_5_95\" class=\"gfield gfield--type-number gfield--input-type-number 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_5_95'>Pago del veh\u00edculo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_95' id='input_5_95' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_95\" \/><div class='gfield_description instruction' id='gfield_instruction_5_95'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><div id=\"field_5_94\" class=\"gfield gfield--type-number gfield--input-type-number 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_5_94'>Seguro<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_94' id='input_5_94' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_94\" \/><div class='gfield_description instruction' id='gfield_instruction_5_94'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><div id=\"field_5_106\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload 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='gform_browse_button_5_106'>Factura de servicios p\u00fablicos m\u00e1s reciente\/actual<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_5_106' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_5_106&quot;,&quot;container&quot;:&quot;gform_multifile_upload_5_106&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_5_106&quot;,&quot;filelist&quot;:&quot;gform_preview_5_106&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/?gf_page=3e476ed529d9fa4&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;134217728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:5,&quot;field_id&quot;:106,&quot;_gform_file_upload_nonce_5_106&quot;:&quot;af166afa3a&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_5_106&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_5_106' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Suelte los archivos aqu\u00ed o <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_5_106' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_5_106\"  >Seleccionar archivos<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_106'>Tama\u00f1o m\u00e1ximo de archivo: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_106'><\/ul> <div id='gform_preview_5_106' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_108\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload 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='gform_browse_button_5_108'>Declaraci\u00f3n m\u00e1s reciente\/actual<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_5_108' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_5_108&quot;,&quot;container&quot;:&quot;gform_multifile_upload_5_108&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_5_108&quot;,&quot;filelist&quot;:&quot;gform_preview_5_108&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/?gf_page=3e476ed529d9fa4&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;134217728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:5,&quot;field_id&quot;:108,&quot;_gform_file_upload_nonce_5_108&quot;:&quot;b153cf597d&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_5_108&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_5_108' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Suelte los archivos aqu\u00ed o <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_5_108' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_5_108\"  >Seleccionar archivos<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_108'>Tama\u00f1o m\u00e1ximo de archivo: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_108'><\/ul> <div id='gform_preview_5_108' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_107\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload 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='gform_browse_button_5_107'>Declaraci\u00f3n m\u00e1s reciente\/actual<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_5_107' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_5_107&quot;,&quot;container&quot;:&quot;gform_multifile_upload_5_107&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_5_107&quot;,&quot;filelist&quot;:&quot;gform_preview_5_107&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/?gf_page=3e476ed529d9fa4&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;134217728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:5,&quot;field_id&quot;:107,&quot;_gform_file_upload_nonce_5_107&quot;:&quot;0938433670&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_5_107&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_5_107' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Suelte los archivos aqu\u00ed o <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_5_107' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_5_107\"  >Seleccionar archivos<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_107'>Tama\u00f1o m\u00e1ximo de archivo: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_107'><\/ul> <div id='gform_preview_5_107' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_97\" class=\"gfield gfield--type-number gfield--input-type-number 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_5_97'>Gastos m\u00e9dicos<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_97' id='input_5_97' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_97\" \/><div class='gfield_description instruction' id='gfield_instruction_5_97'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><div id=\"field_5_98\" class=\"gfield gfield--type-number gfield--input-type-number 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_5_98'>Reparaci\u00f3n: Dom\u00e9stica o de Veh\u00edculos<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_98' id='input_5_98' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_98\" \/><div class='gfield_description instruction' id='gfield_instruction_5_98'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><div id=\"field_5_109\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload 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='gform_browse_button_5_109'>Factura m\u00e1s reciente\/actual<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_5_109' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_5_109&quot;,&quot;container&quot;:&quot;gform_multifile_upload_5_109&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_5_109&quot;,&quot;filelist&quot;:&quot;gform_preview_5_109&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/?gf_page=3e476ed529d9fa4&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;134217728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:5,&quot;field_id&quot;:109,&quot;_gform_file_upload_nonce_5_109&quot;:&quot;aefff5c07f&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_5_109&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_5_109' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Suelte los archivos aqu\u00ed o <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_5_109' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_5_109\"  >Seleccionar archivos<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_109'>Tama\u00f1o m\u00e1ximo de archivo: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_109'><\/ul> <div id='gform_preview_5_109' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_110\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload 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='gform_browse_button_5_110'>Presupuesto o factura de reparaci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_5_110' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_5_110&quot;,&quot;container&quot;:&quot;gform_multifile_upload_5_110&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_5_110&quot;,&quot;filelist&quot;:&quot;gform_preview_5_110&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/?gf_page=3e476ed529d9fa4&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;134217728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:5,&quot;field_id&quot;:110,&quot;_gform_file_upload_nonce_5_110&quot;:&quot;909311cf50&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_5_110&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_5_110' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Suelte los archivos aqu\u00ed o <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_5_110' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_5_110\"  >Seleccionar archivos<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_110'>Tama\u00f1o m\u00e1ximo de archivo: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_110'><\/ul> <div id='gform_preview_5_110' class='ginput_preview_list'><\/div><\/div><\/div><fieldset id=\"field_5_159\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full assistance-field gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Otros gastos\/gastos varios<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Otros gastos\/gastos varios, si procede<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Importe, si procede<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Descripci\u00f3n<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_159_cell1 gform-grid-col' data-label='Other\/Miscellaneous Expenses, if applicable'><input aria-invalid='false' aria-required=\"true\"  aria-label='Otros gastos\/gastos varios, si corresponde, fila 1' data-aria-label-template='Other\/Miscellaneous Expenses, if applicable, Row {0}' type='text' name='input_159[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_159_cell2 gform-grid-col' data-label='Amount, if applicable'><input aria-invalid='false' aria-required=\"true\"  aria-label='Importe, si procede, fila 1' data-aria-label-template='Amount, if applicable, Row {0}' type='text' name='input_159[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_159_cell3 gform-grid-col' data-label='Description'><input aria-invalid='false' aria-required=\"true\"  aria-label='Descripci\u00f3n, Fila 1' data-aria-label-template='Description, Row {0}' type='text' name='input_159[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item' aria-label='A\u00f1ade otra fila' onclick='gformAddListItem(this, 0)'>Agregar<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_5_101\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_5_101'>Otro<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_5_101' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_5_101&quot;,&quot;container&quot;:&quot;gform_multifile_upload_5_101&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_5_101&quot;,&quot;filelist&quot;:&quot;gform_preview_5_101&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/?gf_page=3e476ed529d9fa4&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/vetaffairs.la.gov\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;134217728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:5,&quot;field_id&quot;:101,&quot;_gform_file_upload_nonce_5_101&quot;:&quot;94206dac78&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_5_101&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_5_101' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Suelte los archivos aqu\u00ed o <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_5_101' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_5_101\"  >Seleccionar archivos<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_101'>Tama\u00f1o m\u00e1ximo de archivo: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_101'><\/ul> <div id='gform_preview_5_101' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_102\" class=\"gfield gfield--type-number gfield--input-type-number 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_5_102'>Importe total solicitado (Debe ser una cantidad espec\u00edfica respaldada por la documentaci\u00f3n adjunta arriba)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_102' id='input_5_102' type='text' step='any' min='0'  value='' class='large'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_102\" \/><div class='gfield_description instruction' id='gfield_instruction_5_102'>Introduzca un n\u00famero mayor o igual que <strong>0<\/strong>.<\/div><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_137' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='button' id='gform_next_button_5_137' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Pr\u00f3ximo'  \/> <button type='button'  id='gform_save_5_7_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> GUARDAR Y CONTINUAR M\u00c1S TARDE<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_7' class='gform_page' data-js='page-field-id-137' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_145\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Otra asistencia solicitada antes de solicitar el Fondo MFA<\/h3><\/div><fieldset id=\"field_5_115\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full assistance-field 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' >Asistencia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Fuente<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Fecha de solicitud<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Estado<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Cantidad solicitada<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_115_cell1 gform-grid-col' data-label='Source'><input aria-invalid='false' aria-required=\"true\"  aria-label='Fuente, fila 1' data-aria-label-template='Source, Row {0}' type='text' name='input_115[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_115_cell2 gform-grid-col' data-label='Date Applied'><input aria-invalid='false' aria-required=\"true\"  aria-label='Fecha de solicitud, fila 1' data-aria-label-template='Date Applied, Row {0}' type='text' name='input_115[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_115_cell3 gform-grid-col' data-label='Status'><input aria-invalid='false' aria-required=\"true\"  aria-label='Estado, fila 1' data-aria-label-template='Status, Row {0}' type='text' name='input_115[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_115_cell4 gform-grid-col' data-label='Amount Requested'><input aria-invalid='false' aria-required=\"true\"  aria-label='Cantidad solicitada, fila 1' data-aria-label-template='Amount Requested, Row {0}' type='text' name='input_115[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item' aria-label='A\u00f1ade otra fila' onclick='gformAddListItem(this, 0)'>Agregar<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_5_146\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><div class='gsection_description' id='gfield_description_5_146'>Yo, certifico que la informaci\u00f3n presentada en esta solicitud es veraz y correcta. Mediante mi firma, autorizo la divulgaci\u00f3n de mi informaci\u00f3n personal al Departamento de Asuntos de Veteranos de Luisiana (LDVA) para fines de verificaci\u00f3n. Autorizo al LDVA a acceder a mis registros pertinentes, incluyendo la informaci\u00f3n contenida en DEERS, u otra informaci\u00f3n personal para fines de verificaci\u00f3n. Entiendo que la falta de informaci\u00f3n completa o de documentaci\u00f3n de respaldo impedir\u00e1 el procesamiento de mi solicitud de Autorizaci\u00f3n de Financiamiento de Emergencia (MFA). <br\/> <br\/>\nSi cumplo con los requisitos para recibir fondos, certifico que estos se utilizar\u00e1n para los fines indicados en mi solicitud. Entiendo que, si se aprueba mi solicitud, la ayuda, en la mayor\u00eda de los casos, se pagar\u00e1 directamente al proveedor de servicios y no a m\u00ed. Me comprometo a reembolsar al Fondo MFA si recibo pagos de otra fuente espec\u00edficamente para cubrir la necesidad por la cual solicito la ayuda del MFA. Entiendo que proporcionar informaci\u00f3n falsa de manera intencional y a sabiendas en esta solicitud podr\u00eda resultar en su denegaci\u00f3n.<\/div><\/div><div id=\"field_5_118\" class=\"gfield gfield--type-signature gfield--input-type-signature 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_5_118'>Firma del solicitante<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_5_118_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_5_118_valid' id='input_5_118_valid' \/><canvas id='input_5_118' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/vetaffairs.la.gov\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_5_118_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_5_118_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Firma clara' ><\/div><input type='hidden' id='input_5_118_data' name='input_5_118_data' value=''><\/div><\/div><div id=\"field_5_119\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half 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_5_119'>Fecha<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requerido)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_119' id='input_5_119' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_5_119_date_format gfield_description_5_119\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_119_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_119' class='gform_hidden' value='https:\/\/vetaffairs.la.gov\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_5_119'>Formato: mm\/dd\/aaaa<\/div><\/div><div id=\"field_5_121\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full mfa-form-notice-block mfa-form-notice-block-center blue-background gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><b>Se REQUIEREN copias de la siguiente documentaci\u00f3n:<\/b><\/p>\n<ul>\n<li>Copia del formulario DD214 o certificado de baja del veterano.\n<\/li>\n<li>Prueba de parentesco con un veterano o miembro del servicio militar elegible para los familiares directos que solicitan en nombre del veterano. (Copia de la licencia de matrimonio, certificado de nacimiento, DEERS o poder notarial).\n<\/li>\n<li>Copia de una identificaci\u00f3n con foto v\u00e1lida o identificaci\u00f3n militar\/DEP.\n<\/li>\n<li>Prueba de residencia actual en Luisiana\n<\/li>\n<li>Comprobantes de vacaciones\/ingresos actuales o prueba del ingreso mensual total del hogar\n<\/li>\n<li>Estados de cuenta actuales de facturas, alquiler\/hipoteca y avisos de ejecuci\u00f3n hipotecaria, desalojo y desconexi\u00f3n para aquellos asuntos con los que necesite ayuda.\n<\/li>\n<li>Presupuestos de reparaci\u00f3n u otros servicios, si busca ayuda con una reparaci\u00f3n\/sustituci\u00f3n.\n<\/li>\n<li>Los miembros de la Guardia Nacional\/Reserva o del servicio activo DEBEN proporcionar una copia de sus \u00f3rdenes militares si la activaci\u00f3n les genera dificultades.\n<\/li>\n<\/ul>\n<p><\/p>\n<p>El Fondo de Asistencia para Familias Militares es un fondo de \u00faltimo recurso. Todos los solicitantes deber\u00e1n buscar ayuda en otras fuentes disponibles antes de solicitar el Programa de Asistencia para Familias Militares. Asimismo, deber\u00e1n presentar comprobantes de las solicitudes enviadas a otras fuentes e indicar los montos recibidos.\n<\/p>\n<p>Todos los solicitantes deber\u00e1n proporcionar la documentaci\u00f3n requerida que se detalla anteriormente, as\u00ed como cualquier documentaci\u00f3n adicional que les solicite el Administrador, el Comit\u00e9 o la Junta del MFA. No proporcionar esta informaci\u00f3n dentro del plazo establecido puede resultar en la denegaci\u00f3n de la solicitud.<\/p>\n<p>La solicitud enviada por correo debe contener las FIRMAS ORIGINALES DEL SOLICITANTE donde se solicite.<\/p>\n<p>Por favor, env\u00ede la solicitud completa, junto con toda la documentaci\u00f3n de respaldo REQUERIDA, a:<\/p>\n<p>Departamentos de Asuntos de Veteranos de Luisiana<br>A la atenci\u00f3n del administrador del Ministerio de Asuntos Exteriores<br>Apartado de correos 94095<br>Baton Rouge, Luisiana 70804-9095<\/p><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_5' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Entregar'  \/> <button type='button'  id='gform_save_5_footer_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> GUARDAR Y CONTINUAR M\u00c1S TARDE<\/button>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_5' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' 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