446 lines
24 KiB
HTML
446 lines
24 KiB
HTML
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<!-- Main content -->
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<section class="content">
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<div class="row">
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<!-- right column -->
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<div class="col-md-12">
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<!-- Horizontal Form -->
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<div class="box box-info">
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<div class="box-header with-border">
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<h3 class="box-title"> Enter Your Information Below</h3>
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</div>
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<!-- /.box-header -->
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<!-- form start -->
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<form onsubmit="return getCount()" enctype="multipart/form-data" id="inputformId" class="form-horizontal" method="post" action="__SERVER_URL__webroot/GuestForms/RTG-AAAF-Notice-AFFIANT-AFFIDAVIT-in-AFFIRMATION-of-FACTS-Notice.php">
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<div class="box-body">
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<div class="row">
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<!-- right column -->
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<div class="col-md-10">
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<div class="form-group required">
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<label class="col-sm-5 control-label">AFFIANT</label>
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<div class="col-sm-7">
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<input type="text" name="affiant" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">MONTH</label>
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<div class="col-sm-7">
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<input type="text" name="month" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">DAY</label>
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<div class="col-sm-7">
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<input type="text" name="day" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">YEAR</label>
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<div class="col-sm-7">
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<input type="text" name="year" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">TIME</label>
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<div class="col-sm-7">
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<input type="text" name="time" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">ADDRESSEE</label>
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<div class="col-sm-7">
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<textarea name="addressee" class="form-control" rows="3" cols="47" required></textarea>
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">TRACKING NUMBER</label>
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<div class="col-sm-7">
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<input type="text" name="tracking_number" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">FIRST NAME</label>
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<div class="col-sm-7">
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<input type="text" id="first_name" name="first_name" class="form-control" required>
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">LAST NAME</label>
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<div class="col-sm-7">
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<input type="text" id="last_name" name="last_name" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">STREET NO</label>
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<div class="col-sm-7">
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<input type="text" id="street_no" name="street_no" class="form-control" required>
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">STREET NAME</label>
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<div class="col-sm-7">
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<input type="text" id="street_name" name="street_name" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">CITY</label>
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<div class="col-sm-7">
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<input type="text" id="city" name="city" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">STATE</label>
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<div class="col-sm-7">
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<input type="text" id="state" name="state" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">CURRENT SOCIAL SECURITY NUMBER</label>
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<div class="col-sm-7">
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<input type="text" id="social_security_no" name="current_ssn" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">CURRENT DATE OF BIRTH</label>
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<div class="col-sm-7">
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<input type="text" id="birth_date" name="current_dob" class="form-control" required >
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</div>
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</div>
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<div class="form-group required">
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<label class="col-sm-5 control-label">COUNTRY</label>
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<div class="col-sm-7">
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<input type="text" name="country" class="form-control" required >
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</div>
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</div>
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<hr/>
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</div>
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</div>
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<div class="row">
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<!-- right column -->
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<div class="col-md-10">
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #12:</label>
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<div class="col-sm-7">
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<textarea name="creditor1" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #13</label>
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<div class="col-sm-7">
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<textarea name="creditor2" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #14:</label>
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<div class="col-sm-7">
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<textarea name="creditor3" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #15</label>
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<div class="col-sm-7">
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<textarea name="creditor4" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #16:</label>
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<div class="col-sm-7">
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<textarea name="creditor5" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #17</label>
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<div class="col-sm-7">
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<textarea name="creditor6" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #18:</label>
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<div class="col-sm-7">
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<textarea name="creditor7" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #19</label>
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<div class="col-sm-7">
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<textarea name="creditor8" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #20:</label>
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<div class="col-sm-7">
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<textarea name="creditor9" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #21</label>
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<div class="col-sm-7">
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<textarea name="creditor10" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #22:</label>
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<div class="col-sm-7">
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<textarea name="creditor11" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #23</label>
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<div class="col-sm-7">
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<textarea name="creditor12" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #24:</label>
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<div class="col-sm-7">
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<textarea name="creditor13" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #25</label>
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<div class="col-sm-7">
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<textarea name="creditor14" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #26</label>
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<div class="col-sm-7">
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<textarea name="creditor15" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #27</label>
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<div class="col-sm-7">
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<textarea name="limit_creditor1" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #28</label>
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<div class="col-sm-7">
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<textarea name="limit_creditor2" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #29</label>
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<div class="col-sm-7">
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<textarea name="limit_creditor3" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<div class="form-group">
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<label class="col-sm-5 control-label">AFFIANT FORWARDED FACT #30</label>
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<div class="col-sm-7">
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<textarea name="limit_creditor4" class="form-control" rows="3" cols="47"></textarea>
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</div>
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</div>
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<hr/>
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<!--for uploading media-->
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<div class="form-group" id="uploadSection" style="display:none;">
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<div class="col-sm-3 col-sm-offset-5">
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<button type="button" class="btn btn-primary" data-toggle="modal" data-target=".media-upload-modal-lg">Upload Media</button>
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<div class="modal fade media-upload-modal-lg" tabindex="-1" role="dialog" aria-labelledby="myLargeModalLabel">
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<div class="modal-dialog modal-lg" role="document">
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<div class="modal-content">
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<div class="modal-header">
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<button type="button" class="close" data-dismiss="modal" aria-label="Close"><span aria-hidden="true">×</span></button>
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<h4 class="modal-title" id="gridSystemModalLabel">Upload Media</h4>
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</div>
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<div class="modal-body" id="uploadMediaSection">
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</div>
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</div>
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</div>
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</div>
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</div>
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</div>
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<div class="form-group ">
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<label class="col-sm-5 control-label">Evidence of my Proof of identification<br/>(PNG, JPG,BMP etc. )</label>
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<input type="hidden" value="" name="clientId" id="clientId" class="form-control" >
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<div class="col-sm-5">
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<input type="file" name="image1" id="image1" class="form-control" >
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<input type="hidden" value="" name="image1" id="image1new" class="form-control" >
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<span class="help-block text-center">
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<img id="image1-old-view" alt="" src="" style="margin-top:5px;width:100px;height:100px;"/>
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</span>
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</div>
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<div class="col-sm-2">
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<label id="label1"><a style="cursor:hand;cursor:pointer;" onClick="clearImage('image1');" data-id="4">Clear</a></label>
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</div>
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</div>
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<div class="form-group ">
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<label class="col-sm-5 control-label">Proof of residence or mailing address<br/>(PNG, JPG,BMP etc. )</label>
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<div class="col-sm-5">
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<input type="file" name="image2" id="image2" class="form-control" >
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<input type="hidden" value="" name="image2" id="image2new" class="form-control" >
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<span class="help-block text-center">
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<img id="image2-old-view" alt="" src="" style="margin-top:5px;width:100px;height:100px;"/>
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</span>
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</div>
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<div class="col-sm-2">
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<label id="label2"><a style="cursor:hand;cursor:pointer;" onClick="clearImage('image2');" data-id="4">Clear</a></label>
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</div>
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</div>
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<div class="form-group ">
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<label class="col-sm-5 control-label">Proof of social security number<br/>(PNG, JPG,BMP etc. )</label>
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<div class="col-sm-5">
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<input type="file" name="image3" id="image3" class="form-control" >
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<input type="hidden" value="" name="image3" id="image3new" class="form-control" >
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<span class="help-block text-center">
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<img id="image3-old-view" alt="" src="" style="margin-top:5px;width:100px;height:100px;"/>
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</span>
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</div>
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<div class="col-sm-2">
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<label id="label3"><a style="cursor:hand;cursor:pointer;" onClick="clearImage('image3');" data-id="4">Clear</a></label>
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</div>
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</div>
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<div class="form-group ">
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<label class="col-sm-5 control-label">Your Notarized Letter/form Here(if needed)<br/>(PNG, JPG,BMP etc. )</label>
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<div class="col-sm-5">
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<input type="file" name="image4" id="image4" class="form-control" >
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<input type="hidden" value="" name="image4" id="image5new" class="form-control" >
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<span class="help-block text-center">
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<img id="image5-old-view" alt="" src="" style="margin-top:5px;width:100px;height:100px;"/>
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</span>
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</div>
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<div class="col-sm-2">
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<label id="label5"><a style="cursor:hand;cursor:pointer;" onClick="clearImage('image4');" data-id="4">Clear</a></label>
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</div>
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</div>
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<hr/>
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<div class="form-group">
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<div class="col-sm-offset-5 col-sm-4">
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<button type="button" id="resetForm" class="btn btn-info pull-left">Reset</button>
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<button id="submit" type="submit" class="btn btn-info pull-right">Generate PDF</button>
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</div>
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</div>
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</div>
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</div>
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</div>
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<!-- /.box-body -->
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<div class="box-footer"></div>
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<!-- /.box-footer -->
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</form>
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</div>
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<!-- /.box -->
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</div>
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<!--/.col (right) -->
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</div>
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<!-- /.row -->
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</section>
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<!-- /.content -->
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<script>
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function getCount() {
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var indiactor = false;
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$.ajax({
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type: 'GET',
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url: '__SERVER_URL__/Guestform/getFormDetail/',
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async: false,
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success: function (data) {
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var json = JSON.parse(data);
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var id = json[0].id;
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var form = 'form_62';
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var count = json[0].form_62;
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if (count < __FORM_COUNTED__) {
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increaseCount(count, id, form);
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indiactor = true;
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} else {
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alert("Sorry, you have crossed your free trial limit.");
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indiactor = false;
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}
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}
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});
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return indiactor;
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}
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function increaseCount(count, id, form) {
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$.ajax({
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type: 'POST',
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url: '__SERVER_URL__/Guestform/increaseCount/',
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data: {count: count, id: id, form: form},
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success: function (data) {
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console.log(data);
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var json = JSON.parse(data);
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alert("You have used "+json.count+" out of __FORM_COUNTED__ limit.");
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}
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});
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}
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</script> |