{"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":"quy-ho-tro-gia-dinh-quan-nhan","status":"publish","type":"page","link":"https:\/\/vetaffairs.la.gov\/vi\/military-family-assistance-fund","title":{"rendered":"Qu\u1ef9 h\u1ed7 tr\u1ee3 gia \u0111\u00ecnh qu\u00e2n nh\u00e2n"},"content":{"rendered":"\t\t<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>The Military Family Assistance Fund (MFA) can provide financial support to Louisiana Veterans and their families when they experience financial hardships. Certain criteria applies. In order to receive funds through MFA, a completed application must be submitted to LDVA including all required supporting documentation. MFA can pay up to $10,000.00 for one claim per active-duty order in a twelve month period.<\/p><p>MFA is funded by private donations from individuals and corporations. Visit our How to Help page to donate to the MFA fund.<\/p><p><strong>Qualifications:<\/strong> To qualify for assistance from the MFA Fund, Veterans and activated military applicants must meet certain minimum active-duty service requirements, and have been honorably discharged. Immediate family members of eligible Veterans and activated military personnel may also qualify. Completed applications must include all supporting documents requested on the form.<\/p><p>For more information, you may call toll free <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>The Military Family Assistance Fund (MFA) provides financial assistance to Louisiana veterans and members of the Louisiana National Guard or Reserves who meet eligibility requirements. The MFA Board can approve assistance in an amount up to $10,000 for one need-based claim in a 12-month period.<\/p><p>A veteran of the Armed Forces who received a discharge of honorable or under honorable conditions, or a current member of LANG or Reserves in good standing with their unit, who are current Louisiana residents are eligible to receive assistance. The Military Family Assistance Fund traditionally pays for housing, utilities, some medical services and other essential expenses creating a financial hardship for the veteran or LANG or Reserves service member.<\/p><p>A Louisiana veteran or current member of Louisiana National Guard or Reserves can submit an online application or\u00a0<a href=\"\/wp-content\/uploads\/2021\/09\/MFAApplication.pdf\" target=\"_blank\" rel=\"noopener\">complete a fillable PDF application<\/a> and submit via email to <a href=\"mailto:holly.talley@la.gov\">holly.talley@la.gov <\/a>or fax to (225) 219-5590, or mail to Louisiana Department of Veterans Affairs, ATTN: MFA Administrator, PO Box 94095, Baton Rouge, LA 70804-9095. Applicants may also request an application be sent to them by emailing the address listed above or by calling <a href=\"tel:2252193700\">(225) 219-3700<\/a>.<\/p><p>Note: In order to process all applications as efficiently as possible, please be sure to submit a complete application with all required documents. Funds are not immediately available after submissions as all applications are reviewed by the Military Family Assistance Fund Board at their standing monthly meeting.<\/p><p>Individuals can support Louisiana veterans and current Louisiana National Guard or Reserves service members by making a donation:<\/p><ul><li><a href=\"\/donate\/\">Online<\/a><\/li><li>By mail to: Louisiana Department of Veterans Affairs<br \/>ATTN: MFA Administrator<br \/>PO Box 94095<br \/>Baton Rouge, LA 70804-9095<\/li><li>On an individual or corporate Louisiana tax return<\/li><li>When applying for any class of license at the Office of Motor Vehicles<\/li><li>When purchasing Support Our Veterans and Support Our Troops license plates at the Office of Motor Vehicles<\/li><\/ul><p>For more information about the Military Family Assistance Fund, or help with an application, call <a href=\"tel:2252193700\">(225) 219-3700<\/a> or email <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\">Apply for MFA Funding<\/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 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   <p class='gform_description'><div class=\"gf-logic-announcer sr-only\" aria-live=\"polite\">placeholder<\/div><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_5' id='gform_5' class='mfa-form' action='\/vi\/wp-json\/wp\/v2\/pages\/5562#gf_5' data-formid='5' novalidate>\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=\"126\" \/>\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-sitekey='6LfaguwrAAAAAD1Ru0fYnu0M-b2rk9WNME9ICeAJ' data-tabindex='0'><input id=\"input_baf6c8a8d9651f63d56494042fa96ab9\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_baf6c8a8d9651f63d56494042fa96ab9\" value=\"\"\/><\/div>\n        <div id='gf_progressbar_wrapper_5' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>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>Note: If you would rather not apply online, please download the <a href=\"\/wp-content\/uploads\/2021\/09\/MFAApplication.pdf\" target=\"_blank\">fillable PDF application<\/a> here.<\/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' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_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 '>First<\/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 '>Last<\/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'>Relationship to Veteran<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_3' id='input_5_3' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Relationship<\/option><option value='Veteran' >Veteran<\/option><option value='Spouse' >Spouse<\/option><option value='Child' >Child<\/option><option value='Other' >Other<\/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'>Other<\/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' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_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 '>Street Address<\/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 '>City<\/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' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/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'>Louisiana<\/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' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_5_8_4' id='input_5_8_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/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 '>ZIP Code<\/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'>Please Select Your Parish<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_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'>Select Parish<\/option><option value='Acadia' >Acadia<\/option><option value='Allen' >Allen<\/option><option value='Ascension' >Ascension<\/option><option value='Assumption' >Assumption<\/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' >Evangeline<\/option><option value='Franklin' >Franklin<\/option><option value='Grant' >Grant<\/option><option value='Iberia' >Iberia<\/option><option value='Iberville' >Iberville<\/option><option value='Jackson' >Jackson<\/option><option value='Jefferson' >Jefferson<\/option><option value='Jefferson Davis' >Jefferson Davis<\/option><option value='La Salle' >La Salle<\/option><option value='Lafayette' >Lafayette<\/option><option value='Lafourche' >Lafourche<\/option><option value='Lincoln' >Lincoln<\/option><option value='Livingston' >Livingston<\/option><option value='Madison' >Madison<\/option><option value='Morehouse' >Morehouse<\/option><option value='Natchitoches' >Natchitoches<\/option><option value='Orleans' >Orleans<\/option><option value='Ouachita' >Ouachita<\/option><option value='Plaquemines' >Plaquemines<\/option><option value='Pointe Coupee' >Pointe Coupee<\/option><option value='Rapides' >Rapides<\/option><option value='Red River' >Red River<\/option><option value='Richland' >Richland<\/option><option value='Sabine' >Sabine<\/option><option value='St. Bernard' >St. Bernard<\/option><option value='St. Charles' >St. Charles<\/option><option value='St. Helena' >St. Helena<\/option><option value='St. James' >St. James<\/option><option value='St. John The Baptist' >St. John The Baptist<\/option><option value='St. Landry' >St. Landry<\/option><option value='St. Martin' >St. Martin<\/option><option value='St. Mary' >St. Mary<\/option><option value='St. Tammany' >St. 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' >Vermilion<\/option><option value='Vernon' >Vernon<\/option><option value='Washington' >Washington<\/option><option value='Webster' >Webster<\/option><option value='West Baton Rouge' >West Baton Rouge<\/option><option value='West Carroll' >West Carroll<\/option><option value='West Feliciana' >West Feliciana<\/option><option value='Winn' >Winn<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_5_7'>Please select the Parish where you currently reside from the list above.<\/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'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_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: sample@domain.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'>Cell Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_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'>Home Phone<\/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'>Work Phone<\/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'>Marital Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_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'>Marriage License<\/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'>Max. file size: 128 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_5_14'><\/div> <\/div><\/div><div id=\"field_5_15\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_15'>Birth Certificate or Power of Attorney<\/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'>Max. file size: 128 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_5_15'><\/div> <\/div><\/div><div id=\"field_5_16\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_16'>Number of Dependents\/Children in Household<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_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'>Veteran Photo ID<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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'>Max. file size: 128 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_5_17'><\/div> <\/div><\/div><div id=\"field_5_18\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_5_18'>Spouse or Others Above the Age of 18 Photo ID(s)<\/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;6f0c65d240&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'>Drop files here or <\/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\"  >Select files<\/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'>Max. file size: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_18'><\/ul> <div id='gform_preview_5_18' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_42\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_5_42'>Ages of Children<\/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=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_5_43'>Special Needs?<\/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'>Ages of Children<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_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'>Special Needs<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_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='Next'  \/> <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> SAVE AND CONTINUE LATER<\/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\">Veteran\/Service Member&#039;s Contact Information<\/h3><div class='gsection_description' id='gfield_description_5_140'>This information is for the veteran only if he\/she is not the applicant.<\/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'>Email Address<\/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: sample@domain.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'>Home Phone<\/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'>Cell Phone<\/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'>Work Phone<\/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='Previous'  \/> <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='Next'  \/> <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> SAVE AND CONTINUE LATER<\/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\">Veteran\/Service Member Information<\/h3><div class='gsection_description' id='gfield_description_5_141'>As it appears on DD214 or Military Orders<\/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' >I am currently serving<\/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'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_149_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='No'  id='choice_5_149_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_149_1' id='label_5_149_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_28\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_28'>DD214 Or Discharge<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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'>Max. file size: 128 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_5_28'><\/div> <\/div><\/div><fieldset id=\"field_5_29\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_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 '>First<\/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 '>Middle<\/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 '>Last<\/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' >Current LA Resident?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_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'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_5_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_30_1' id='label_5_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_31'>Branch of Service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_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'>Rank<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_5_32' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_34\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_34'>Total Years of Service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_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'>Entered Service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_35' id='input_5_35' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' 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 slash DD slash YYYY<\/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\/dd\/yyyy<\/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'>Exited Service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_36' id='input_5_36' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' 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 slash DD slash YYYY<\/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\/dd\/yyyy<\/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 of Assignment (If currently assigned)<\/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 of Activation (If currently activated)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_41' id='input_5_41' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' 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 slash DD slash YYYY<\/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\/dd\/yyyy<\/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' >Are you a current member of the LA National Guard or Reserves?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_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'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No'  id='choice_5_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_38_1' id='label_5_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_40\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_40'>Military Orders<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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'>Max. file size: 128 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_5_40'><\/div> <\/div><\/div><div id=\"field_5_166\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Military Unit Point of Contact for Verification<\/h3><div class='gsection_description' id='gfield_description_5_166'>For current Guard\/Reserve\/Active Duty ONLY)<\/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'>Unit Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_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'>Rank\/Title<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_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'>Unit Contact Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_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: sample@domain.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--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_170'>Unit Contact Work Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_170' id='input_5_170' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_5_170\"  \/><\/div><div class='gfield_description' id='gfield_description_5_170'>Format: (123) 456-7890<\/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--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_171'>Unit Contact Fax Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_171' id='input_5_171' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_5_171\"  \/><\/div><div class='gfield_description' id='gfield_description_5_171'>Format: (123) 456-7890<\/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'>I attest that the information provided in this application is true and correct to the best of my knowledge. I understand that there is no guarantee my application will be granted. I also understand that if my application is granted, assistance will, in most cases, be paid directly to the service provider and not me.<\/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\">(Required)<\/span><\/span><\/label><input type='hidden' value='' name='input_172' id='input_5_172_signature_filename'\/><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; ' ><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='Clear Signature' \/ ><\/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\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_173' id='input_5_173' type='text' value='04\/20\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' 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 slash DD slash YYYY<\/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\/dd\/yyyy<\/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>Please complete this form in its entirely. The information will be used to assess our ability to assist you.<\/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'>Please explain: specific amount needed? Why do you need assistance? Please list all other sources as insurance and military programs to which you have applied. Attach additional paper if needed.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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>Examples of Eligible Expenses:<\/b><\/p>\n<ul>\n<li>Household Expenses: Mortgage, Rent, and some repairs for primary residence.<\/li>\n<li>Utilities: Electricity, Gas, Water, Sewage, and Garbage.<\/li>\n<li>Vehicle Expenses: Payments, Insurance, and some major repairs.<\/li>\n<li>Food and Clothing<\/li>\n<li>Some Medical Expenses can be considered.<\/li>\n<li>Expenses determined to be a basic life need that creates an undue financial hardship.<\/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>Examples of Expenses NOT Eligible:<\/b><\/p>\n<ul>\n<li>Home purchases or home improvements<\/li>\n<li>Income Property Expenses or Repairs<\/li>\n<li>Credit Card Bills or Military Charge Cards<\/li>\n<li>Payment of fines or legal expenses.<\/li>\n<li>Finance of leave or vacation time.<\/li>\n<li>Cable, Internet, or Secondary Phones<\/li>\n<li>Cosmetic or Investigational medical procedures and expenses.<\/li>\n<li>Taxes - property or otherwise<\/li>\n<li>Non-essentials for basic life needs.<\/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>The eligible and ineligible expenses listed are not all inclusive. All applications are individually reviewed. The MFA Administrator, Committee and Board reserve the right to make exceptions on a case-by-case basis. Each application will be carefully reviewed for its own merits.<\/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='Previous'  \/> <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='Next'  \/> <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> SAVE AND CONTINUE LATER<\/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'>List all that apply <br\/> <br\/>\n<strong>Important:<\/strong> Must include ALL recurring monthly household income for ALL members of the household (Veteran\/Service Member, Spouse, etc.) Please include verification of income; for example, last two pay stubs, most recent VA award letter, Social Security benefits letter for the current year, 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\">Monthly Income Earnings ($)<\/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'>Veteran<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_59' id='input_5_59' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_59\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_59'>Please enter a number greater than or equal to <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' >Spouse\/Household Members 18+<\/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='Spouse\/Household Members 18+, Row 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='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_157'>If applicable<\/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\">Monthly Military Salary ($) (If Applicable)<\/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'>Veteran<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_62' id='input_5_62' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_62\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_62'>Please enter a number greater than or equal to <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' >Spouse\/Household Members 18+<\/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='Spouse\/Household Members 18+, Row 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='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_156'>If applicable<\/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\">Social Security Income\/Disability ($)<\/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'>Veteran<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_65' id='input_5_65' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_65\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_65'>Please enter a number greater than or equal to <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' >Spouse\/Household Members 18+<\/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='Spouse\/Household Members 18+, Row 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='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_155'>If applicable<\/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\">VA Pension or Other VA Benefits ($)<\/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'>Veteran<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_68' id='input_5_68' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_68\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_68'>Please enter a number greater than or equal to <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' >Spouse\/Household Members 18+<\/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='Spouse\/Household Members 18+, Row 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='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_154'>If applicable<\/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\">Retirement Income ($)<\/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'>Veteran<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_71' id='input_5_71' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_71\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_71'>Please enter a number greater than or equal to <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' >Spouse\/Household Members 18+<\/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='Spouse\/Household Members 18+, Row 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='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_153'>If applicable<\/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\">Public Assistance (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'>Veteran<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_130' id='input_5_130' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_130\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_130'>Please enter a number greater than or equal to <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' >Spouse\/Household Members 18+<\/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='Spouse\/Household Members 18+, Row 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='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_151'>If applicable<\/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'>Other Income<\/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'>Veteran<\/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'>Please enter a number greater than or equal to <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' >Spouse\/Household Members 18+<\/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='Spouse\/Household Members 18+, Row 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='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_152'>If applicable<\/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'>Total Household Income<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_74' id='input_5_74' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_74\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_74'>Please enter a number greater than or equal to <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='Previous'  \/> <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='Next'  \/> <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> SAVE AND CONTINUE LATER<\/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\">Average Household Monthly Expenses<\/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'>Mortgage\/Rent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_80' id='input_5_80' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_80\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_80'>Please enter a number greater than or equal to <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'>Electricity \/ Gas<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_81' id='input_5_81' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_81\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_81'>Please enter a number greater than or equal to <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'>Water, Sewage, Garbage<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_82' id='input_5_82' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_82\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_82'>Please enter a number greater than or equal to <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'>Food\/Clothing<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_85' id='input_5_85' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_85\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_85'>Please enter a number greater than or equal to <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'>Vehicle Payment(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_84' id='input_5_84' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_84\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_84'>Please enter a number greater than or equal to <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'>Insurance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_83' id='input_5_83' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_83\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_83'>Please enter a number greater than or equal to <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\">(Required)<\/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\">Other\/Miscellaneous Expenses, if applicable<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Amount, if applicable<\/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='Other\/Miscellaneous Expenses, if applicable, Row 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='Amount, if applicable, Row 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, Row 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='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_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'>Total Household Expenses<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_88' id='input_5_88' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_88\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_88'>Please enter a number greater than or equal to <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='Previous'  \/> <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='Next'  \/> <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> SAVE AND CONTINUE LATER<\/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\">Expenses and Amount Requested<\/h3><div class='gsection_description' id='gfield_description_5_144'>List total amounts owed for each of the bills that you are requesting assistance to pay. Documentation is required to support the specific amounts(s) being requested. Documentation includes, but is not limited to: copies of mortgage\/lease, bills, invoices\/receipts, repair estimates, cancellation notices, eviction\/foreclosure\/repossession notices, or any other similar records. Amounts requested will not be considered without ALL required supporting documentation.<\/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'>Mortgage\/Rent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_91' id='input_5_91' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_91\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_91'>Please enter a number greater than or equal to <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'>Utilities: Electricity<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_92' id='input_5_92' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_92\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_92'>Please enter a number greater than or equal to <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'>Utilities: Water, Sewage, Garbage<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_93' id='input_5_93' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_93\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_93'>Please enter a number greater than or equal to <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'>Mortgage Statement; or Full Lease &amp; Landlord Contract Info.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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;dd74dc344c&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'>Drop files here or <\/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\"  >Select files<\/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'>Max. file size: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_103'><\/ul> <div id='gform_preview_5_103' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_104\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_5_104'>Most Recent\/Current Utility Bill<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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;a10cfcf32d&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'>Drop files here or <\/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\"  >Select files<\/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'>Max. file size: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_104'><\/ul> <div id='gform_preview_5_104' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_105\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_5_105'>Most Recent\/Current Utility Bill<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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;f8f9f08bb1&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'>Drop files here or <\/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\"  >Select files<\/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'>Max. file size: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_105'><\/ul> <div id='gform_preview_5_105' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_96\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_96'>Utilities: Gas<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_96' id='input_5_96' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_96\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_96'>Please enter a number greater than or equal to <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'>Vehicle Payment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_95' id='input_5_95' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_95\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_95'>Please enter a number greater than or equal to <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'>Insurance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_94' id='input_5_94' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_94\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_94'>Please enter a number greater than or equal to <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'>Most Recent\/Current Utility Bill<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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;fd7c3ea6dd&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'>Drop files here or <\/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\"  >Select files<\/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'>Max. file size: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_106'><\/ul> <div id='gform_preview_5_106' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_108\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_5_108'>Most Recent\/Current Statement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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;15e050a9c8&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'>Drop files here or <\/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\"  >Select files<\/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'>Max. file size: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_108'><\/ul> <div id='gform_preview_5_108' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_107\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_5_107'>Most Recent\/Current Statement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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;5675dccbb8&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'>Drop files here or <\/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\"  >Select files<\/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'>Max. file size: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_107'><\/ul> <div id='gform_preview_5_107' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_97\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_97'>Medical Expense<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_97' id='input_5_97' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_97\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_97'>Please enter a number greater than or equal to <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'>Repair: Household or Vehicle<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_98' id='input_5_98' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_98\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_98'>Please enter a number greater than or equal to <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'>Most Recent\/Current Bill<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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;a1a337231d&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'>Drop files here or <\/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\"  >Select files<\/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'>Max. file size: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_109'><\/ul> <div id='gform_preview_5_109' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_110\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_5_110'>Repair Estimate or Invoice<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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;674d2df995&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'>Drop files here or <\/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\"  >Select files<\/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'>Max. file size: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_110'><\/ul> <div id='gform_preview_5_110' class='ginput_preview_list'><\/div><\/div><\/div><fieldset id=\"field_5_159\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full assistance-field gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Other\/Miscellaneous Expenses<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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\">Other\/Miscellaneous Expenses, if applicable<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Amount, if applicable<\/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='Other\/Miscellaneous Expenses, if applicable, Row 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='Amount, if applicable, Row 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, Row 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='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_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'>Other<\/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;914536f49c&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'>Drop files here or <\/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\"  >Select files<\/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'>Max. file size: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_101'><\/ul> <div id='gform_preview_5_101' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_5_102\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_102'>Total Amount Requested (Must be specific amount supported by documentation, attached above)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_102' id='input_5_102' type='text' step='any' min='0'  value='' class='large'    placeholder='Amount' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_102\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_102'>Please enter a number greater than or equal to <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='Previous'  \/> <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='Next'  \/> <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> SAVE AND CONTINUE LATER<\/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\">Other assistance sought before applying to the MFA Fund<\/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\">(Required)<\/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 Applied<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Status<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Amount Requested<\/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, Row 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 Applied, Row 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='Status, Row 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='Amount Requested, Row 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='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_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'>I, certify the information submitted within this application to be true and correct. By my signature, I authorize release of the privacy information to LDVA for vertification purposes. I authorize access by the Lousiana Department of Veterans Affairs to my pertinent records, including information maintained within DEERS, or other privacy information for verification purposes. I understand that failure to provide complete information and\/or supporting documentation will prohibit the processing of my MFA application. <br\/> <br\/>\nIf eligible to receive funds, I certify these funds will be used for the reasons indicated in my application. I understand that if my application is granted, assistance will, in most cases, be paid directly to the service provider and not to me. I promise to repay MFA Fund if I receive payments from another source specifically to satisfy the need for which I am requesting MFA assistance. I understand that willfully and knowingly providing false information on this application could result in the denial of my application.<\/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'>Applicant Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><input type='hidden' value='' name='input_118' id='input_5_118_signature_filename'\/><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; ' ><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='Clear Signature' \/ ><\/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\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_119' id='input_5_119' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' 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 slash DD slash YYYY<\/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\/dd\/yyyy<\/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>Copies of the following documentation is REQUIRED:<\/b><\/p>\n<ul>\n<li>Copy of Veteran's DD214 or Discharge\n<\/li>\n<li>Proof of Relationship to eligible Veteran or service member for immediate family members applying on Veteran's behalf. (Copy of Marriage License, Birth Certificate, DEERS, or Power of Attorney).\n<\/li>\n<li>Copy of Valid Photo ID or Military\/DEP. ID\n<\/li>\n<li>Proof of Current Louisiana Residency\n<\/li>\n<li>Current Leave\/Earnings Statements or Proof of Total Household Monthly Income\n<\/li>\n<li>Current Statements for bills, rent\/mortgage, and foreclosure, eviction, and disconnection notices for items with which you need help.\n<\/li>\n<li>Repair or other estimates, if seeking assistance with a repair\/replacement.\n<\/li>\n<li>Guard\/Reserve or Active Duty Service Members MUST provide a copy of military orders, if hardship is created by activation.\n<\/li>\n<\/ul>\n<p><\/p>\n<p>The Military Family Assistance Fund is a fund of last resort. All applicants shall seek assistance from other available sources prior to making an application to the MFA Program. 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