{"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":"fonds-daide-aux-familles-de-militaires","status":"publish","type":"page","link":"https:\/\/vetaffairs.la.gov\/fr\/fonds-daide-aux-familles-de-militaires","title":{"rendered":"Fonds d&#039;aide aux familles de militaires"},"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>Le Fonds d&#039;aide aux familles de militaires (MFA) peut apporter un soutien financier aux v\u00e9t\u00e9rans de Louisiane et \u00e0 leurs familles confront\u00e9s \u00e0 des difficult\u00e9s financi\u00e8res. Certaines conditions s&#039;appliquent. Pour b\u00e9n\u00e9ficier de l&#039;aide du MFA, un formulaire de demande d\u00fbment rempli, accompagn\u00e9 de toutes les pi\u00e8ces justificatives requises, doit \u00eatre soumis au D\u00e9partement des anciens combattants de Louisiane (LDVA). Le MFA peut verser jusqu&#039;\u00e0 1\u00a0040\u00a0000 $ par demande et par ordre de mission, sur une p\u00e9riode de douze mois.<\/p><p>Le MFA est financ\u00e9 par des dons priv\u00e9s de particuliers et d&#039;entreprises. Consultez notre page \u00ab\u00a0Comment nous aider\u00a0\u00bb pour faire un don au fonds du MFA.<\/p><p><strong>Qualifications:<\/strong> Pour b\u00e9n\u00e9ficier de l&#039;aide du Fonds MFA, les anciens combattants et les militaires en service actif doivent satisfaire \u00e0 certaines exigences minimales de service actif et avoir \u00e9t\u00e9 lib\u00e9r\u00e9s honorablement du service. Les membres de la famille imm\u00e9diate des anciens combattants et des militaires en service actif admissibles peuvent \u00e9galement \u00eatre admissibles. Les demandes d\u00fbment remplies doivent inclure tous les documents justificatifs demand\u00e9s sur le formulaire.<\/p><p>Pour plus d&#039;informations, vous pouvez appeler gratuitement <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>Le Fonds d&#039;aide aux familles de militaires (MFA) offre une aide financi\u00e8re aux anciens combattants de Louisiane et aux membres de la Garde nationale ou des r\u00e9serves de Louisiane qui remplissent les conditions d&#039;admissibilit\u00e9. Le conseil d&#039;administration du MFA peut approuver une aide pouvant atteindre 1\u00a0040\u00a0000 $ pour une demande fond\u00e9e sur les besoins, sur une p\u00e9riode de 12 mois.<\/p><p>Les anciens combattants des forces arm\u00e9es ayant re\u00e7u une lib\u00e9ration honorable ou sous conditions honorables, ainsi que les membres actifs de la Garde nationale de Louisiane (LANG) ou des r\u00e9serves en r\u00e8gle avec leur unit\u00e9, r\u00e9sidant actuellement en Louisiane, sont admissibles \u00e0 une aide financi\u00e8re. Le Fonds d&#039;assistance aux familles de militaires prend g\u00e9n\u00e9ralement en charge le logement, les services publics, certains services m\u00e9dicaux et d&#039;autres d\u00e9penses essentielles engendrant des difficult\u00e9s financi\u00e8res pour les anciens combattants, les membres de la LANG ou les r\u00e9servistes.<\/p><p>Un ancien combattant de Louisiane ou un membre actuel de la Garde nationale ou des r\u00e9serves de Louisiane peut soumettre une demande en ligne ou\u00a0<a href=\"\/wp-content\/uploads\/2021\/09\/MFAApplication.pdf\" target=\"_blank\" rel=\"noopener\">remplir un formulaire PDF interactif<\/a> et soumettre par courriel \u00e0 <a href=\"mailto:holly.talley@la.gov\">holly.talley@la.gov <\/a>ou par fax au (225) 219-5590, ou par courrier \u00e0 l&#039;adresse suivante\u00a0: Louisiana Department of Veterans Affairs, ATTN\u00a0: MFA Administrator, PO Box 94095, Baton Rouge, LA 70804-9095. Les candidats peuvent \u00e9galement demander qu&#039;un formulaire de demande leur soit envoy\u00e9 par courriel \u00e0 l&#039;adresse indiqu\u00e9e ci-dessus ou par t\u00e9l\u00e9phone. <a href=\"tel:2252193700\">(225) 219-3700<\/a>.<\/p><p>Remarque\u00a0: Afin de traiter toutes les demandes le plus efficacement possible, veuillez vous assurer de soumettre un dossier complet accompagn\u00e9 de tous les documents requis. Les fonds ne sont pas disponibles imm\u00e9diatement apr\u00e8s le d\u00e9p\u00f4t de la demande, car toutes les demandes sont examin\u00e9es par le conseil d\u2019administration du Fonds d\u2019aide aux familles de militaires lors de sa r\u00e9union mensuelle.<\/p><p>Les particuliers peuvent soutenir les anciens combattants de Louisiane et les membres actuels de la Garde nationale ou des r\u00e9serves de Louisiane en faisant un don\u00a0:<\/p><ul><li><a href=\"\/fr\/faire-un-don\/\">En ligne<\/a><\/li><li>Par courrier \u00e0 : D\u00e9partement des affaires des anciens combattants de la Louisiane<br \/>\u00c0 l&#039;attention de l&#039;administrateur MFA<br \/>Bo\u00eete postale 94095<br \/>Baton Rouge, LA 70804-9095<\/li><li>Sur une d\u00e9claration de revenus de Louisiane, individuelle ou d&#039;entreprise<\/li><li>Lors de la demande d&#039;un permis de conduire, quel qu&#039;en soit le type, aupr\u00e8s du Bureau des v\u00e9hicules automobiles<\/li><li>Lors de l&#039;achat de plaques d&#039;immatriculation \u00ab\u00a0Soutien \u00e0 nos v\u00e9t\u00e9rans\u00a0\u00bb et \u00ab\u00a0Soutien \u00e0 nos troupes\u00a0\u00bb au bureau des v\u00e9hicules automobiles<\/li><\/ul><p>Pour plus d&#039;informations sur le Fonds d&#039;aide aux familles de militaires ou pour obtenir de l&#039;aide concernant une demande, appelez le num\u00e9ro indiqu\u00e9. <a href=\"tel:2252193700\">(225) 219-3700<\/a> ou par courriel <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\">Demande de financement pour le 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 class=\"elementor-shortcode\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital mfa-form_wrapper' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_5' style='display:none'><style>#gform_wrapper_5[data-form-index=\"0\"].gform-theme,[data-parent-form=\"5_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: #585e6a;--gf-color-out-ctrl-dark-rgb: 88, 94, 106;--gf-color-out-ctrl-dark-darker: #112337;--gf-color-out-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-color-in-ctrl: #fff;--gf-color-in-ctrl-rgb: 255, 255, 255;--gf-color-in-ctrl-contrast: #112337;--gf-color-in-ctrl-contrast-rgb: 17, 35, 55;--gf-color-in-ctrl-darker: #F5F5F5;--gf-color-in-ctrl-lighter: #FFFFFF;--gf-color-in-ctrl-primary: #204ce5;--gf-color-in-ctrl-primary-rgb: 32, 76, 229;--gf-color-in-ctrl-primary-contrast: #fff;--gf-color-in-ctrl-primary-contrast-rgb: 255, 255, 255;--gf-color-in-ctrl-primary-darker: #001AB3;--gf-color-in-ctrl-primary-lighter: #527EFF;--gf-color-in-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-in-ctrl-light-rgb: 17, 35, 55;--gf-color-in-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-in-ctrl-light-lighter: #F5F5F5;--gf-color-in-ctrl-dark: #585e6a;--gf-color-in-ctrl-dark-rgb: 88, 94, 106;--gf-color-in-ctrl-dark-darker: #112337;--gf-color-in-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-radius: 3px;--gf-font-size-secondary: 14px;--gf-font-size-tertiary: 13px;--gf-icon-ctrl-number: url(\"data:image\/svg+xml,%3Csvg width='8' height='14' viewBox='0 0 8 14' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-select: url(\"data:image\/svg+xml,%3Csvg width='10' height='6' viewBox='0 0 10 6' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg width='640' height='640' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_5' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5' class='mfa-form' action='\/fr\/wp-json\/wp\/v2\/pages\/5562#gf_5' data-formid='5' novalidate data-trp-original-action=\"\/fr\/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=\"37\" \/>\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\">\u00c9tape <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>Remarque : Si vous pr\u00e9f\u00e9rez ne pas postuler en ligne, veuillez t\u00e9l\u00e9charger le formulaire. <a href=\"\/wp-content\/uploads\/2021\/09\/MFAApplication.pdf\" target=\"_blank\">application PDF remplissable<\/a> ici.<\/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' >Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>D&#039;abord<\/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'>Dernier<\/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'>Lien avec un ancien combattant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>S\u00e9lectionner la relation<\/option><option value='Veteran' >V\u00e9t\u00e9ran<\/option><option value='Spouse' >Conjoint<\/option><option value='Child' >Enfant<\/option><option value='Other' >Autre<\/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'>Autre<\/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' >Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>Adresse de la rue<\/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'>Ville<\/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 am\u00e9ricaines<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >Californie<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >district f\u00e9d\u00e9ral de Columbia<\/option><option value='Florida' >Floride<\/option><option value='Georgia' >G\u00e9orgie<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/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'>Louisiane<\/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' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >Caroline du Nord<\/option><option value='North Dakota' >Dakota du Nord<\/option><option value='Northern Mariana Islands' >\u00celes Mariannes du Nord<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvanie<\/option><option value='Puerto Rico' >Porto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >Caroline du Sud<\/option><option value='South Dakota' >Dakota du Sud<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >\u00celes Vierges am\u00e9ricaines<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginie<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >Virginie-Occidentale<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Forces arm\u00e9es des Am\u00e9riques<\/option><option value='Armed Forces Europe' >Forces arm\u00e9es europ\u00e9ennes<\/option><option value='Armed Forces Pacific' >Forces arm\u00e9es du Pacifique<\/option><\/select>\n                                        <label for='input_5_8_4' id='input_5_8_4_label' class='gform-field-label gform-field-label--type-sub'>\u00c9tat<\/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'>Code 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'>Veuillez s\u00e9lectionner votre paroisse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>S\u00e9lectionner la paroisse<\/option><option value='Acadia' >Acadie<\/option><option value='Allen' >Allen<\/option><option value='Ascension' >Ascension<\/option><option value='Assumption' >Hypoth\u00e8se<\/option><option value='Avoyelles' >Avoyelles<\/option><option value='Beauregard' >Beauregard<\/option><option value='Bienville' >Bienville<\/option><option value='Bossier' >Bossier<\/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' >East Carroll<\/option><option value='East Feliciana' >East Feliciana<\/option><option value='Evangeline' >\u00c9vang\u00e9line<\/option><option value='Franklin' >Franklin<\/option><option value='Grant' >Accorder<\/option><option value='Iberia' >Ib\u00e9rie<\/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' >Orl\u00e9ans<\/option><option value='Ouachita' >Ouachita<\/option><option value='Plaquemines' >Plaquemines<\/option><option value='Pointe Coupee' >Pointe Coup\u00e9e<\/option><option value='Rapides' >Rapides<\/option><option value='Red River' >Rivi\u00e8re Rouge<\/option><option value='Richland' >Richland<\/option><option value='Sabine' >Sabine<\/option><option value='St. Bernard' >Saint-Bernard<\/option><option value='St. Charles' >Saint-Charles<\/option><option value='St. Helena' >Sainte-H\u00e9l\u00e8ne<\/option><option value='St. James' >Saint-Jacques<\/option><option value='St. John The Baptist' >Saint Jean-Baptiste<\/option><option value='St. Landry' >Saint Landry<\/option><option value='St. Martin' >Saint-Martin<\/option><option value='St. Mary' >Sainte Marie<\/option><option value='St. Tammany' >Saint-Tammany<\/option><option value='Tangipahoa' >Tangipahoa<\/option><option value='Tensas' >Tensas<\/option><option value='Terrebonne' >Terrebonne<\/option><option value='Union' >Union<\/option><option value='Vermilion' >Vermillon<\/option><option value='Vernon' >Vernon<\/option><option value='Washington' >Washington<\/option><option value='Webster' >Webster<\/option><option value='West Baton Rouge' >Ouest de Baton Rouge<\/option><option value='West Carroll' >West Carroll<\/option><option value='West Feliciana' >West Feliciana<\/option><option value='Winn' >Gagner<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_5_7'>Veuillez s\u00e9lectionner dans la liste ci-dessus la paroisse o\u00f9 vous r\u00e9sidez actuellement.<\/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'>E-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>Format\u00a0: nom_utilisateur@domaine.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'>T\u00e9l\u00e9phone portable<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>Format : (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'>T\u00e9l\u00e9phone fixe<\/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'>Format : (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'>T\u00e9l\u00e9phone professionnel<\/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'>Format : (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'>\u00c9tat civil<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>Licence de mariage<\/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'>Taille maximale du fichier\u00a0: 128\u00a0Mo.<\/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'>Certificat de naissance ou procuration<\/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'>Taille maximale du fichier\u00a0: 128\u00a0Mo.<\/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'>Nombre de personnes \u00e0 charge\/enfants dans le m\u00e9nage<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>Carte d&#039;identit\u00e9 avec photo pour v\u00e9t\u00e9ran<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>Taille maximale du fichier\u00a0: 128\u00a0Mo.<\/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'>Pi\u00e8ce d&#039;identit\u00e9 avec photo du conjoint ou d&#039;autres personnes \u00e2g\u00e9es de plus de 18 ans<\/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;1daccdcc5d&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'>D\u00e9posez les fichiers ici ou <\/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\"  >S\u00e9lectionner les fichiers<\/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'>Taille maximale du fichier\u00a0: 128\u00a0Mo.<\/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=\"Ce champ est masqu\u00e9 lors de l&#039;affichage du formulaire.\"><\/i><span>Ce champ est masqu\u00e9 lors de l&#039;affichage du formulaire.<\/span><\/div><label class='gfield_label gform-field-label' for='input_5_42'>\u00c2ges des enfants<\/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=\"Ce champ est masqu\u00e9 lors de l&#039;affichage du formulaire.\"><\/i><span>Ce champ est masqu\u00e9 lors de l&#039;affichage du formulaire.<\/span><\/div><label class='gfield_label gform-field-label' for='input_5_43'>Besoins sp\u00e9ciaux ?<\/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'>\u00c2ges des enfants<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>Besoins sp\u00e9ciaux<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Suivant'  \/> <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> ENREGISTRER ET CONTINUER PLUS TARD<\/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\">Coordonn\u00e9es des anciens combattants\/membres des forces arm\u00e9es<\/h3><div class='gsection_description' id='gfield_description_5_140'>Ces informations concernent uniquement le v\u00e9t\u00e9ran s&#039;il n&#039;est pas le demandeur.<\/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'>Adresse email<\/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'>Format\u00a0: nom_utilisateur@domaine.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'>T\u00e9l\u00e9phone fixe<\/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'>Format : (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'>T\u00e9l\u00e9phone portable<\/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'>Format : (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'>T\u00e9l\u00e9phone professionnel<\/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'>Format : (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='Pr\u00e9c\u00e9dent'  \/> <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='Suivant'  \/> <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> ENREGISTRER ET CONTINUER PLUS TARD<\/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\">Informations pour les anciens combattants et les militaires<\/h3><div class='gsection_description' id='gfield_description_5_141'>Tel qu&#039;il appara\u00eet sur le formulaire DD214 ou les ordres militaires<\/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' >Je suis actuellement en service<\/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'>Oui<\/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'>Non<\/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 ou cong\u00e9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>Taille maximale du fichier\u00a0: 128\u00a0Mo.<\/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' >Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>D&#039;abord<\/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'>Milieu<\/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'>Dernier<\/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' >R\u00e9sident actuel de Los Angeles ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>Oui<\/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'>Non<\/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'>Branche du service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>Rang<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>Nombre total d&#039;ann\u00e9es de service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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\u00e9 en service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='jj\/mm\/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\/JJ\/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'>Format : mm\/jj\/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'>Service quitt\u00e9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='jj\/mm\/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\/JJ\/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'>Format : mm\/jj\/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'>Unit\u00e9 d&#039;affectation (si actuellement affect\u00e9e)<\/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'>Date d&#039;activation (si actuellement activ\u00e9)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='jj\/mm\/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\/JJ\/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'>Format : mm\/jj\/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' >\u00cates-vous actuellement membre de la Garde nationale ou des r\u00e9serves de Los Angeles\u00a0?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>Oui<\/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'>Non<\/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'>Ordres militaires<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>Taille maximale du fichier\u00a0: 128\u00a0Mo.<\/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\">Unit\u00e9 militaire de contact pour la v\u00e9rification<\/h3><div class='gsection_description' id='gfield_description_5_166'>R\u00e9serv\u00e9 aux membres actuels de la Garde nationale, de la R\u00e9serve et du Service actif.<\/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'>Nom de l&#039;unit\u00e9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>Grade\/Titre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>Adresse courriel de contact de l&#039;unit\u00e9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>Format\u00a0: nom_utilisateur@domaine.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'>Num\u00e9ro de t\u00e9l\u00e9phone professionnel de la personne \u00e0 contacter au sein de l&#039;unit\u00e9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>Num\u00e9ro de fax de contact de l&#039;unit\u00e9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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'>J&#039;atteste que les informations fournies dans cette demande sont exactes et v\u00e9ridiques, \u00e0 ma connaissance. Je comprends qu&#039;il n&#039;y a aucune garantie que ma demande sera accept\u00e9e. Je comprends \u00e9galement que si ma demande est accept\u00e9e, l&#039;aide sera, dans la plupart des cas, vers\u00e9e directement au prestataire de services et non \u00e0 moi.<\/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'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Signature claire' ><\/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'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_173' id='input_5_173' type='text' value='04\/06\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='jj\/mm\/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\/JJ\/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'>Format : mm\/jj\/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>Veuillez remplir ce formulaire dans son int\u00e9gralit\u00e9. Les informations recueillies nous permettront d&#039;\u00e9valuer notre capacit\u00e9 \u00e0 vous aider.<\/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'>Veuillez pr\u00e9ciser le montant exact dont vous avez besoin et pourquoi vous sollicitez cette aide. Veuillez indiquer toutes les autres sources de financement, telles que les assurances et les programmes militaires, auxquelles vous avez fait une demande. Joignez des documents suppl\u00e9mentaires si n\u00e9cessaire.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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>Exemples de d\u00e9penses admissibles\u00a0:<\/b><\/p>\n<ul>\n<li>D\u00e9penses du m\u00e9nage\u00a0: cr\u00e9dit immobilier, loyer et certaines r\u00e9parations de la r\u00e9sidence principale.<\/li>\n<li>Services publics : \u00e9lectricit\u00e9, gaz, eau, assainissement et ordures m\u00e9nag\u00e8res.<\/li>\n<li>Frais li\u00e9s au v\u00e9hicule\u00a0: paiements, assurance et certaines r\u00e9parations importantes.<\/li>\n<li>Nourriture et v\u00eatements<\/li>\n<li>Certaines d\u00e9penses m\u00e9dicales peuvent \u00eatre prises en compte.<\/li>\n<li>D\u00e9penses consid\u00e9r\u00e9es comme des besoins essentiels qui engendrent des difficult\u00e9s financi\u00e8res excessives.<\/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>Exemples de d\u00e9penses NON admissibles\u00a0:<\/b><\/p>\n<ul>\n<li>Achat ou r\u00e9novation d&#039;une maison<\/li>\n<li>D\u00e9penses ou r\u00e9parations relatives aux immeubles de rapport<\/li>\n<li>Relev\u00e9s de cartes de cr\u00e9dit ou cartes de cr\u00e9dit militaires<\/li>\n<li>Paiement des amendes ou des frais juridiques.<\/li>\n<li>Financement des cong\u00e9s ou des vacances.<\/li>\n<li>C\u00e2ble, Internet ou t\u00e9l\u00e9phones secondaires<\/li>\n<li>Interventions et frais m\u00e9dicaux \u00e0 vis\u00e9e esth\u00e9tique ou exp\u00e9rimentale.<\/li>\n<li>Imp\u00f4ts - fonciers ou autres<\/li>\n<li>Articles non essentiels pour les besoins fondamentaux de la vie.<\/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>La liste des d\u00e9penses admissibles et non admissibles n&#039;est pas exhaustive. Chaque demande est examin\u00e9e individuellement. L&#039;administrateur, le comit\u00e9 et le conseil d&#039;administration du MFA se r\u00e9servent le droit d&#039;accorder des d\u00e9rogations au cas par cas. Chaque demande sera \u00e9tudi\u00e9e avec soin en fonction de ses propres m\u00e9rites.<\/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='Pr\u00e9c\u00e9dent'  \/> <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='Suivant'  \/> <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> ENREGISTRER ET CONTINUER PLUS TARD<\/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'>\u00c9num\u00e9rez toutes les r\u00e9ponses qui s&#039;appliquent. <br\/> <br\/>\n<strong>Important:<\/strong> Doit inclure TOUS les revenus mensuels r\u00e9currents du m\u00e9nage pour TOUS les membres du m\u00e9nage (ancien combattant\/membre des forces arm\u00e9es, conjoint, etc.). Veuillez inclure une preuve de revenu ; par exemple, les deux derniers bulletins de paie, la lettre d&#039;attribution de l&#039;Administration des anciens combattants la plus r\u00e9cente, la lettre de prestations de la S\u00e9curit\u00e9 sociale pour l&#039;ann\u00e9e en cours, 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\">Revenus mensuels ($)<\/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'>V\u00e9t\u00e9ran<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_59\" \/><div class='gfield_description instruction' id='gfield_instruction_5_59'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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' >Conjoint\/Membres du foyer \u00e2g\u00e9s de 18 ans et plus<\/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='Conjoint\/Membres du foyer \u00e2g\u00e9s de 18 ans et plus, rang\u00e9e 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='Ajouter une autre ligne' onclick='gformAddListItem(this, 0)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Retirer<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_157'>Le cas \u00e9ch\u00e9ant<\/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\">Solde militaire mensuel ($) (le cas \u00e9ch\u00e9ant)<\/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'>V\u00e9t\u00e9ran<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_62\" \/><div class='gfield_description instruction' id='gfield_instruction_5_62'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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' >Conjoint\/Membres du foyer \u00e2g\u00e9s de 18 ans et plus<\/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='Conjoint\/Membres du foyer \u00e2g\u00e9s de 18 ans et plus, rang\u00e9e 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='Ajouter une autre ligne' onclick='gformAddListItem(this, 0)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Retirer<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_156'>Le cas \u00e9ch\u00e9ant<\/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\">Revenu\/invalidit\u00e9 de la s\u00e9curit\u00e9 sociale ($)<\/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'>V\u00e9t\u00e9ran<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_65\" \/><div class='gfield_description instruction' id='gfield_instruction_5_65'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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' >Conjoint\/Membres du foyer \u00e2g\u00e9s de 18 ans et plus<\/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='Conjoint\/Membres du foyer \u00e2g\u00e9s de 18 ans et plus, rang\u00e9e 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='Ajouter une autre ligne' onclick='gformAddListItem(this, 0)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Retirer<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_155'>Le cas \u00e9ch\u00e9ant<\/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\">Pension d&#039;invalidit\u00e9 ou autres prestations d&#039;invalidit\u00e9 ($)<\/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'>V\u00e9t\u00e9ran<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_68\" \/><div class='gfield_description instruction' id='gfield_instruction_5_68'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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' >Conjoint\/Membres du foyer \u00e2g\u00e9s de 18 ans et plus<\/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='Conjoint\/Membres du foyer \u00e2g\u00e9s de 18 ans et plus, rang\u00e9e 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='Ajouter une autre ligne' onclick='gformAddListItem(this, 0)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Retirer<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_154'>Le cas \u00e9ch\u00e9ant<\/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\">Revenu de retraite ($)<\/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'>V\u00e9t\u00e9ran<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_71\" \/><div class='gfield_description instruction' id='gfield_instruction_5_71'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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' >Conjoint\/Membres du foyer \u00e2g\u00e9s de 18 ans et plus<\/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='Conjoint\/Membres du foyer \u00e2g\u00e9s de 18 ans et plus, rang\u00e9e 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='Ajouter une autre ligne' onclick='gformAddListItem(this, 0)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Retirer<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_153'>Le cas \u00e9ch\u00e9ant<\/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\">Aide sociale (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'>V\u00e9t\u00e9ran<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_130\" \/><div class='gfield_description instruction' id='gfield_instruction_5_130'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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' >Conjoint\/Membres du foyer \u00e2g\u00e9s de 18 ans et plus<\/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='Conjoint\/Membres du foyer \u00e2g\u00e9s de 18 ans et plus, rang\u00e9e 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='Ajouter une autre ligne' onclick='gformAddListItem(this, 0)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Retirer<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_151'>Le cas \u00e9ch\u00e9ant<\/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'>Autres revenus<\/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'>V\u00e9t\u00e9ran<\/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'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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' >Conjoint\/Membres du foyer \u00e2g\u00e9s de 18 ans et plus<\/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='Conjoint\/Membres du foyer \u00e2g\u00e9s de 18 ans et plus, rang\u00e9e 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='Ajouter une autre ligne' onclick='gformAddListItem(this, 0)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Retirer<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_152'>Le cas \u00e9ch\u00e9ant<\/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'>Revenu total des m\u00e9nages<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_74\" \/><div class='gfield_description instruction' id='gfield_instruction_5_74'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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='Pr\u00e9c\u00e9dent'  \/> <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='Suivant'  \/> <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> ENREGISTRER ET CONTINUER PLUS TARD<\/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\">D\u00e9penses mensuelles moyennes des m\u00e9nages<\/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'>Pr\u00eat hypoth\u00e9caire\/Loyer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_80\" \/><div class='gfield_description instruction' id='gfield_instruction_5_80'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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'>\u00c9lectricit\u00e9 \/ Gaz<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_81\" \/><div class='gfield_description instruction' id='gfield_instruction_5_81'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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'>Eau, eaux us\u00e9es, ordures<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_82\" \/><div class='gfield_description instruction' id='gfield_instruction_5_82'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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'>Nourriture\/V\u00eatements<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_85\" \/><div class='gfield_description instruction' id='gfield_instruction_5_85'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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'>Paiement(s) du v\u00e9hicule<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_84\" \/><div class='gfield_description instruction' id='gfield_instruction_5_84'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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'>Assurance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_83\" \/><div class='gfield_description instruction' id='gfield_instruction_5_83'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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' >Assistance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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\">Autres frais\/d\u00e9penses diverses, le cas \u00e9ch\u00e9ant<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Montant, le cas \u00e9ch\u00e9ant<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Description<\/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='Autres d\u00e9penses\/d\u00e9penses diverses, le cas \u00e9ch\u00e9ant, ligne 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='Montant, le cas \u00e9ch\u00e9ant, ligne 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='Description, ligne 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='Ajouter une autre ligne' onclick='gformAddListItem(this, 0)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Retirer<\/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'>D\u00e9penses totales du m\u00e9nage<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_88\" \/><div class='gfield_description instruction' id='gfield_instruction_5_88'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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='Pr\u00e9c\u00e9dent'  \/> <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='Suivant'  \/> <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> ENREGISTRER ET CONTINUER PLUS TARD<\/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\">D\u00e9penses et montant demand\u00e9<\/h3><div class='gsection_description' id='gfield_description_5_144'>Veuillez indiquer le montant total d\u00fb pour chacune des factures pour lesquelles vous sollicitez une aide au paiement. Des justificatifs sont requis pour chaque montant demand\u00e9. Ces justificatifs comprennent, sans s&#039;y limiter\u00a0: copies de votre contrat de pr\u00eat immobilier\/bail, factures, re\u00e7us, devis de r\u00e9paration, avis de r\u00e9siliation, avis d&#039;expulsion\/de saisie\/de reprise de possession, ou tout autre document similaire. Les demandes de remboursement ne seront pas prises en compte sans l&#039;ensemble des justificatifs requis.<\/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'>Pr\u00eat hypoth\u00e9caire\/Loyer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_91\" \/><div class='gfield_description instruction' id='gfield_instruction_5_91'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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'>Services publics : \u00c9lectricit\u00e9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_92\" \/><div class='gfield_description instruction' id='gfield_instruction_5_92'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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'>Services publics\u00a0: eau, \u00e9gouts, ordures m\u00e9nag\u00e8res<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_93\" \/><div class='gfield_description instruction' id='gfield_instruction_5_93'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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'>Relev\u00e9 hypoth\u00e9caire ; ou informations compl\u00e8tes sur le bail et le contrat avec le propri\u00e9taire.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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;91ae42fb3e&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'>D\u00e9posez les fichiers ici ou <\/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\"  >S\u00e9lectionner les fichiers<\/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'>Taille maximale du fichier\u00a0: 128\u00a0Mo.<\/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'>Facture de service public la plus r\u00e9cente\/actuelle<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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;c501304c7b&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'>D\u00e9posez les fichiers ici ou <\/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\"  >S\u00e9lectionner les fichiers<\/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'>Taille maximale du fichier\u00a0: 128\u00a0Mo.<\/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'>Facture de service public la plus r\u00e9cente\/actuelle<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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;8749a4c6b2&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'>D\u00e9posez les fichiers ici ou <\/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\"  >S\u00e9lectionner les fichiers<\/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'>Taille maximale du fichier\u00a0: 128\u00a0Mo.<\/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'>Services publics\u00a0: Gaz<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_96\" \/><div class='gfield_description instruction' id='gfield_instruction_5_96'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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'>Paiement du v\u00e9hicule<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_95\" \/><div class='gfield_description instruction' id='gfield_instruction_5_95'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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'>Assurance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_94\" \/><div class='gfield_description instruction' id='gfield_instruction_5_94'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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'>Facture de service public la plus r\u00e9cente\/actuelle<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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;514c458b01&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'>D\u00e9posez les fichiers ici ou <\/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\"  >S\u00e9lectionner les fichiers<\/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'>Taille maximale du fichier\u00a0: 128\u00a0Mo.<\/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'>D\u00e9claration la plus r\u00e9cente\/actuelle<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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;c30b2ef12c&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'>D\u00e9posez les fichiers ici ou <\/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\"  >S\u00e9lectionner les fichiers<\/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'>Taille maximale du fichier\u00a0: 128\u00a0Mo.<\/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'>D\u00e9claration la plus r\u00e9cente\/actuelle<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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;81cbfc3289&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'>D\u00e9posez les fichiers ici ou <\/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\"  >S\u00e9lectionner les fichiers<\/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'>Taille maximale du fichier\u00a0: 128\u00a0Mo.<\/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'>Frais m\u00e9dicaux<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_97\" \/><div class='gfield_description instruction' id='gfield_instruction_5_97'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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'>R\u00e9paration : domestique ou v\u00e9hicule<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_98\" \/><div class='gfield_description instruction' id='gfield_instruction_5_98'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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'>Facture la plus r\u00e9cente\/actuelle<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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;75ac659828&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'>D\u00e9posez les fichiers ici ou <\/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\"  >S\u00e9lectionner les fichiers<\/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'>Taille maximale du fichier\u00a0: 128\u00a0Mo.<\/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'>Devis ou facture de r\u00e9paration<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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;682d4f23f7&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'>D\u00e9posez les fichiers ici ou <\/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\"  >S\u00e9lectionner les fichiers<\/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'>Taille maximale du fichier\u00a0: 128\u00a0Mo.<\/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' >Autres d\u00e9penses\/d\u00e9penses diverses<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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\">Autres frais\/d\u00e9penses diverses, le cas \u00e9ch\u00e9ant<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Montant, le cas \u00e9ch\u00e9ant<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Description<\/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='Autres d\u00e9penses\/d\u00e9penses diverses, le cas \u00e9ch\u00e9ant, ligne 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='Montant, le cas \u00e9ch\u00e9ant, ligne 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='Description, ligne 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='Ajouter une autre ligne' onclick='gformAddListItem(this, 0)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Retirer<\/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'>Autre<\/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;be59ce0ac6&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'>D\u00e9posez les fichiers ici ou <\/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\"  >S\u00e9lectionner les fichiers<\/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'>Taille maximale du fichier\u00a0: 128\u00a0Mo.<\/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'>Montant total demand\u00e9 (Doit \u00eatre un montant pr\u00e9cis justifi\u00e9 par les documents joints ci-dessus)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Montant' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_102\" \/><div class='gfield_description instruction' id='gfield_instruction_5_102'>Veuillez saisir un nombre sup\u00e9rieur ou \u00e9gal \u00e0 <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='Pr\u00e9c\u00e9dent'  \/> <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='Suivant'  \/> <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> ENREGISTRER ET CONTINUER PLUS TARD<\/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\">Autres formes d&#039;aide sollicit\u00e9es avant de soumettre une demande au Fonds 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' >Assistance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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\">Source<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Date de la demande<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Statut<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Montant demand\u00e9<\/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='Source, ligne 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='Date d&#039;application, ligne 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='Statut, ligne 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='Montant demand\u00e9, ligne 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='Ajouter une autre ligne' onclick='gformAddListItem(this, 0)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Retirer<\/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'>Je soussign\u00e9(e), certifie que les informations fournies dans cette demande sont exactes et v\u00e9ridiques. Par ma signature, j&#039;autorise la communication de mes informations personnelles au D\u00e9partement des affaires des anciens combattants de la Louisiane (LDVA) \u00e0 des fins de v\u00e9rification. J&#039;autorise le LDVA \u00e0 acc\u00e9der \u00e0 mon dossier, y compris aux informations conserv\u00e9es dans le DEERS, ainsi qu&#039;\u00e0 toute autre information personnelle, \u00e0 des fins de v\u00e9rification. Je comprends que le d\u00e9faut de fournir des informations compl\u00e8tes et\/ou des pi\u00e8ces justificatives entra\u00eenera le rejet de ma demande d&#039;aide m\u00e9dicale d&#039;urgence (MFA). <br\/> <br\/>\nSi je suis admissible \u00e0 recevoir des fonds, je certifie que ces fonds seront utilis\u00e9s aux fins indiqu\u00e9es dans ma demande. Je comprends que si ma demande est accept\u00e9e, l&#039;aide sera, dans la plupart des cas, vers\u00e9e directement au prestataire de services et non \u00e0 moi. Je m&#039;engage \u00e0 rembourser le Fonds MFA si je re\u00e7ois des paiements d&#039;une autre source sp\u00e9cifiquement destin\u00e9s \u00e0 satisfaire le besoin pour lequel je sollicite l&#039;aide du MFA. Je comprends que fournir sciemment et volontairement de fausses informations dans cette demande pourrait entra\u00eener son rejet.<\/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'>Signature du demandeur<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='Signature claire' ><\/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'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Requis)<\/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='jj\/mm\/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\/JJ\/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'>Format : mm\/jj\/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>Les copies des documents suivants sont OBLIGATOIRES\u00a0:<\/b><\/p>\n<ul>\n<li>Copie du formulaire DD214 ou du certificat de lib\u00e9ration du v\u00e9t\u00e9ran\n<\/li>\n<li>Preuve de lien de parent\u00e9 avec un ancien combattant ou un membre des forces arm\u00e9es admissible pour les membres de la famille imm\u00e9diate qui pr\u00e9sentent une demande au nom de l&#039;ancien combattant. (Copie d&#039;un certificat de mariage, d&#039;un certificat de naissance, d&#039;un relev\u00e9 DEERS ou d&#039;une procuration).\n<\/li>\n<li>Copie d&#039;une pi\u00e8ce d&#039;identit\u00e9 avec photo valide ou d&#039;une carte d&#039;identit\u00e9 militaire\/DEP.\n<\/li>\n<li>Preuve de r\u00e9sidence actuelle en Louisiane\n<\/li>\n<li>Relev\u00e9s de cong\u00e9s\/salaires actuels ou preuve du revenu mensuel total du m\u00e9nage\n<\/li>\n<li>Relev\u00e9s actuels de factures, de loyer\/hypoth\u00e8que, et d&#039;avis de saisie, d&#039;expulsion et de coupure pour les \u00e9l\u00e9ments pour lesquels vous avez besoin d&#039;aide.\n<\/li>\n<li>Devis de r\u00e9paration ou autres, si vous avez besoin d&#039;aide pour une r\u00e9paration\/un remplacement.\n<\/li>\n<li>Les membres de la Garde nationale, de la R\u00e9serve ou du service actif DOIVENT fournir une copie de leurs ordres militaires si leur activation leur cause des difficult\u00e9s.\n<\/li>\n<\/ul>\n<p><\/p>\n<p>Le Fonds d&#039;aide aux familles de militaires est un fonds de dernier recours. Tous les demandeurs doivent solliciter l&#039;aide d&#039;autres sources disponibles avant de soumettre une demande au Programme d&#039;aide aux familles de militaires. Ils doivent \u00e9galement fournir la preuve des demandes soumises \u00e0 d&#039;autres organismes et indiquer les montants re\u00e7us.\n<\/p>\n<p>Tous les candidats doivent fournir les documents requis mentionn\u00e9s ci-dessus, ainsi que tout document suppl\u00e9mentaire pouvant \u00eatre demand\u00e9 par l&#039;administrateur, le comit\u00e9 ou le conseil d&#039;administration du MFA. Le d\u00e9faut de fournir ces informations dans les d\u00e9lais impartis peut entra\u00eener le rejet de la candidature.<\/p>\n<p>Toute demande envoy\u00e9e par courrier doit comporter la SIGNATURE ORIGINALE DU DEMANDEUR aux endroits indiqu\u00e9s.<\/p>\n<p>Veuillez envoyer par courrier le formulaire de demande d\u00fbment rempli, accompagn\u00e9 de tous les documents justificatifs REQUIS, \u00e0 l&#039;adresse suivante\u00a0:<\/p>\n<p>D\u00e9partements des affaires des anciens combattants de la Louisiane<br>\u00c0 l&#039;attention de l&#039;administrateur MFA<br>Bo\u00eete postale 94095<br>Baton Rouge, Louisiane 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='Pr\u00e9c\u00e9dent'  \/> <input type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Soumettre'  \/> <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> ENREGISTRER ET CONTINUER PLUS TARD<\/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' data-js='gform_theme_5' id='gform_theme_5' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_5' id='gform_style_settings_5' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='5' \/>\n            <input type='hidden' class='gform_hidden' name='gform_save' id='gform_save_5' value='' \/>\n                             <input type='hidden' class='gform_hidden' name='gform_resume_token' id='gform_resume_token_5' value='' \/>\n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='C5O9X7LQ5u3uBlGxmjOrn9kvdVREHJ3Pe82JGTkOGrUPYeg1dYfVL4myP98E0kvmPyN4tSn+HAjc\/4jxzjk9AMYCKKN14chEAdIITbLLoVXGGVs=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_5' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_5' id='gform_target_page_number_5' value='2' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_5' id='gform_source_page_number_5' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            <input type='hidden' name='gform_uploaded_files' id='gform_uploaded_files_5' value='' \/>\n        <\/div>\n             <\/div><\/div>\n                        <input type=\"hidden\" name=\"trp-form-language\" value=\"fr\"\/><\/form>\n                        <\/div><script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 5, 'https:\/\/vetaffairs.la.gov\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', false );jQuery('#gform_ajax_frame_5').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_5');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_5').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_5').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_5').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_5').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_5').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_5').val();gformInitSpinner( 5, 'https:\/\/vetaffairs.la.gov\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', false );jQuery(document).trigger('gform_page_loaded', [5, current_page]);window['gf_submitting_5'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_5').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_5').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [5]);window['gf_submitting_5'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_5').text());}else{jQuery('#gform_5').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"5\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_5\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_5\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_5\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 5, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} );\n<\/script>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"<p>Le Fonds d&#039;aide aux familles de militaires (MFA) peut apporter un soutien financier aux v\u00e9t\u00e9rans de Louisiane et \u00e0 leurs familles confront\u00e9s \u00e0 des difficult\u00e9s financi\u00e8res. Certaines conditions s&#039;appliquent. Pour b\u00e9n\u00e9ficier de l&#039;aide du MFA, un formulaire de demande d\u00fbment rempli, accompagn\u00e9 de toutes les pi\u00e8ces justificatives requises, doit \u00eatre soumis au D\u00e9partement des anciens combattants de Louisiane (LDVA). Le MFA peut verser jusqu&#039;\u00e0 1\u00a0040\u00a0000 $ par demande et par v\u00e9t\u00e9ran en service actif.<\/p>","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-5562","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/vetaffairs.la.gov\/fr\/wp-json\/wp\/v2\/pages\/5562","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/vetaffairs.la.gov\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/vetaffairs.la.gov\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/vetaffairs.la.gov\/fr\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/vetaffairs.la.gov\/fr\/wp-json\/wp\/v2\/comments?post=5562"}],"version-history":[{"count":0,"href":"https:\/\/vetaffairs.la.gov\/fr\/wp-json\/wp\/v2\/pages\/5562\/revisions"}],"wp:attachment":[{"href":"https:\/\/vetaffairs.la.gov\/fr\/wp-json\/wp\/v2\/media?parent=5562"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}