{"id":5546,"date":"2024-04-26T12:12:24","date_gmt":"2024-04-26T16:12:24","guid":{"rendered":"https:\/\/www.loudouncares.org\/?page_id=5546"},"modified":"2024-04-26T12:28:47","modified_gmt":"2024-04-26T16:28:47","slug":"examen-previo-reu-v2","status":"publish","type":"page","link":"https:\/\/www.loudouncares.org\/es\/examen-previo-reu-v2\/","title":{"rendered":"Examen previo REU v2"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of 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   <h2 class=\"gform_title\">Pre-Screening Questionnaire<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/es\/wp-json\/wp\/v2\/pages\/5546#gf_2' data-formid='2' novalidate>\n        <div id='gf_progressbar_wrapper_2' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Paso <span class='gf_step_current_page'>1<\/span> de <span class='gf_step_page_count'>3<\/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_33' style='width:33%;'><span>33%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_2_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_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_2_49\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_49'>Instagram<\/label><div class='gfield_description' id='gfield_description_2_49'>Este campo es un campo de validaci\u00f3n y debe quedar sin cambios.<\/div><div class='ginput_container'><input name='input_49' id='input_2_49' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_2_46\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p>Please note: Your name must be on the primary lease agreement in order to complete this pre-screen. The Rent Assistance &#038; Eviction Prevention Programs do not cover sub-leasing arrangements. Please contact our ConnectLine if you have questions.<\/p><\/div><fieldset id=\"field_2_1\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><html><body><legend class=\"gfield_label gform-field-label\"><gftt-label class=\"gftt-label\">Do you live in Loudoun County?<span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/gftt-label><i id=\"gftt-2_1\" class=\"gftt-icon gform-theme__no-reset--el\" tabindex=\"0\" data-placement=\"nw-alt\"><\/i><div class=\"gftt-content\" id=\"gftt-2_1-wrap\" role=\"tooltip\" aria-hidden=\"false\"><div id=\"gftt-2_1-content\" data-tid=\"gftt-2_1\" aria-hidden=\"false\"><strong>There are seven (7) towns in Loudon County: <\/strong><br><br>\n\u2023 Town of Hamilton<br>\u2023 Town of Hillsboro<br>\u2023 Town of Leesburg<br>\u2023 Town of Lovettsville<br>\u2023 Town of Middleburg<br>\u2023 Town of Purcellville<br>\u2023 Town of Round Hill<\/div><\/div><\/legend><div class=\"gfield_description\" id=\"gfield_description_2_1\"><p><strong>Loudoun Cares provides assistance for Loudoun County residents only.<\/strong> Not sure if you live in Loudoun County? Hover over question mark above for a list of applicable towns. <br>Please contact your local Department of Family Services about any assistance they may be able to offer.<\/p>\n<p>\u2023 Fairfax County, VA: (703) 324-7500<br>\n\u2023 Clarke County, VA: (540) 955-3700<br>\n\u2023 Fauquier County, VA: (540) 422-8400<br>\n\u2023 Prince William County, VA: (703) 792-7500<br>\n\u2023 Frederick County, MD: (301) 600-1200<\/p><\/div><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_2_1\">\n\t\t\t<div class=\"gchoice gchoice_2_1_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_1\" type=\"radio\" value=\"Yes, I live in Loudoun County.\" id=\"choice_2_1_0\" onchange=\"gformToggleRadioOther( this )\" aria-describedby=\"gftt-2_1-wrap\">\n\t\t\t\t\t<label for=\"choice_2_1_0\" id=\"label_2_1_0\" class=\"gform-field-label gform-field-label--type-inline\">Yes, I live in Loudoun County.<\/label>\n\t\t\t<\/div><\/div><\/div><\/body><\/html><\/fieldset><fieldset id=\"field_2_3\" 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_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you rent or own your home?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_3'>\n\t\t\t<div class='gchoice gchoice_2_3_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Rent'  id='choice_2_3_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_3_0' id='label_2_3_0' class='gform-field-label gform-field-label--type-inline'>Rent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_3_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Own'  id='choice_2_3_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_3_1' id='label_2_3_1' class='gform-field-label gform-field-label--type-inline'>Own<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_4\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What kind of assistance do you need?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_4'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_4'><div class='gchoice gchoice_2_4_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.1' type='checkbox'  value='Rental Assistance'  id='choice_2_4_1'   aria-describedby=\"gfield_description_2_4\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_4_1' id='label_2_4_1' class='gform-field-label gform-field-label--type-inline'>Rental Assistance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_4_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.2' type='checkbox'  value='Utility Assistance'  id='choice_2_4_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_4_2' id='label_2_4_2' class='gform-field-label gform-field-label--type-inline'>Utility Assistance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_4_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.3' type='checkbox'  value='Other (i.e., car repair, diapers, food, medical, etc.)'  id='choice_2_4_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_4_3' id='label_2_4_3' class='gform-field-label gform-field-label--type-inline'>Other (i.e., car repair, diapers, food, medical, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_6\" 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_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >What is your current primary rental concern?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_6'>\n\t\t\t<div class='gchoice gchoice_2_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='I have a 5-Day or 30-Day Pay or Quit Notice.'  id='choice_2_6_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_6_0' id='label_2_6_0' class='gform-field-label gform-field-label--type-inline'>I have a 5-Day or 30-Day Pay or Quit Notice.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='I have been struggling to pay my rent for months.'  id='choice_2_6_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_6_1' id='label_2_6_1' class='gform-field-label gform-field-label--type-inline'>I have been struggling to pay my rent for months.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_5\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What kind of assistance do you need?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_5'>Select all that apply.<\/br> \nPlease note that we do not offer mortgage assistance at this time.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_5'><div class='gchoice gchoice_2_5_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.1' type='checkbox'  value='Utility Assistance'  id='choice_2_5_1'   aria-describedby=\"gfield_description_2_5\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_5_1' id='label_2_5_1' class='gform-field-label gform-field-label--type-inline'>Utility Assistance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_5_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.2' type='checkbox'  value='Other (i.e., car repair, diapers, food, medical, etc.)'  id='choice_2_5_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_5_2' id='label_2_5_2' class='gform-field-label gform-field-label--type-inline'>Other (i.e., car repair, diapers, food, medical, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_2_34' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_2' class='gform_page' data-js='page-field-id-34' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_2_48\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p>Please note: To be eligible for funding, you must meet the following requirements: <\/p>\n<li>You must be experiencing a housing cost burden (rent is more than 30% of household income).<\/li>\n<li>Your household income (before taxes) must be 80% or below the Area Median Income (AMI).<\/li>\n<li>Your household must have experienced economic hardship due to COVID-19 (more details follow).<\/li><\/div><div id=\"field_2_35\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Household Information<\/h3><div class='gsection_description' id='gfield_description_2_35'>The following information help us determine the types and sources of assistance for which you may qualify.<\/div><\/div><div id=\"field_2_7\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_7'>How many people live in your household?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_7'>This includes all people, regardless of age or relation, that currently live in your home.<\/div><div class='ginput_container ginput_container_select'><select name='input_7' id='input_2_7' class='large gfield_select'  aria-describedby=\"gfield_description_2_7\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='0' >0<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><\/select><\/div><\/div><fieldset id=\"field_2_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $86,700\/year ($7,225\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_8'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_8'>\n\t\t\t<div class='gchoice gchoice_2_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Yes'  id='choice_2_8_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_8\"   \/>\n\t\t\t\t\t<label for='choice_2_8_0' id='label_2_8_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_2_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='No'  id='choice_2_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_8_1' id='label_2_8_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $99,050\/year ($8,254\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_10'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_10'>\n\t\t\t<div class='gchoice gchoice_2_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Yes'  id='choice_2_10_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_10\"   \/>\n\t\t\t\t\t<label for='choice_2_10_0' id='label_2_10_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_2_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='No'  id='choice_2_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_10_1' id='label_2_10_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $111,450\/year ($9,288\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_11'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_11'>\n\t\t\t<div class='gchoice gchoice_2_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Yes'  id='choice_2_11_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_11\"   \/>\n\t\t\t\t\t<label for='choice_2_11_0' id='label_2_11_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_2_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='No'  id='choice_2_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_11_1' id='label_2_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $123,800\/year ($10,317\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_12'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_12'>\n\t\t\t<div class='gchoice gchoice_2_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Yes'  id='choice_2_12_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_12\"   \/>\n\t\t\t\t\t<label for='choice_2_12_0' id='label_2_12_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_2_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='No'  id='choice_2_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_12_1' id='label_2_12_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $133,750\/year ($11,146\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_13'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_13'>\n\t\t\t<div class='gchoice gchoice_2_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes'  id='choice_2_13_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_13\"   \/>\n\t\t\t\t\t<label for='choice_2_13_0' id='label_2_13_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_2_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='No'  id='choice_2_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_13_1' id='label_2_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $143,650\/year ($11,971\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_14'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_14'>\n\t\t\t<div class='gchoice gchoice_2_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Yes'  id='choice_2_14_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_14\"   \/>\n\t\t\t\t\t<label for='choice_2_14_0' id='label_2_14_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_2_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='No'  id='choice_2_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_14_1' id='label_2_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $153,550\/year ($12,796\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_15'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_15'>\n\t\t\t<div class='gchoice gchoice_2_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Yes'  id='choice_2_15_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_15\"   \/>\n\t\t\t\t\t<label for='choice_2_15_0' id='label_2_15_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_2_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No'  id='choice_2_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_15_1' id='label_2_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $163,450\/year ($13,621\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_16'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_16'>\n\t\t\t<div class='gchoice gchoice_2_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Yes'  id='choice_2_16_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_16\"   \/>\n\t\t\t\t\t<label for='choice_2_16_0' id='label_2_16_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_2_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='No'  id='choice_2_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_16_1' id='label_2_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $173,320\/year ($14,443\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_42'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_42'>\n\t\t\t<div class='gchoice gchoice_2_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Yes'  id='choice_2_42_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_42\"   \/>\n\t\t\t\t\t<label for='choice_2_42_0' id='label_2_42_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_2_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='No'  id='choice_2_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_42_1' id='label_2_42_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $183,224\/year ($15,269\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_43'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_43'>\n\t\t\t<div class='gchoice gchoice_2_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Yes'  id='choice_2_43_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_43\"   \/>\n\t\t\t\t\t<label for='choice_2_43_0' id='label_2_43_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_2_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='No'  id='choice_2_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_43_1' id='label_2_43_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $43,350\/year ($3,613\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_18'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_18'>\n\t\t\t<div class='gchoice gchoice_2_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Yes'  id='choice_2_18_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_18\"   \/>\n\t\t\t\t\t<label for='choice_2_18_0' id='label_2_18_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_2_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='No'  id='choice_2_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_18_1' id='label_2_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $49,550\/year ($4,129\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_17'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_17'>\n\t\t\t<div class='gchoice gchoice_2_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Yes'  id='choice_2_17_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_17\"   \/>\n\t\t\t\t\t<label for='choice_2_17_0' id='label_2_17_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_2_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='No'  id='choice_2_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_17_1' id='label_2_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $55,750\/year ($4,646\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_19'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_19'>\n\t\t\t<div class='gchoice gchoice_2_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_2_19_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_19\"   \/>\n\t\t\t\t\t<label for='choice_2_19_0' id='label_2_19_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_2_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_2_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_19_1' id='label_2_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $61,900\/year ($5,158\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_20'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_20'>\n\t\t\t<div class='gchoice gchoice_2_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Yes'  id='choice_2_20_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_20\"   \/>\n\t\t\t\t\t<label for='choice_2_20_0' id='label_2_20_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_2_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='No'  id='choice_2_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_20_1' id='label_2_20_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $66,900\/year ($5,575\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_21'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_21'>\n\t\t\t<div class='gchoice gchoice_2_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_2_21_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_21\"   \/>\n\t\t\t\t\t<label for='choice_2_21_0' id='label_2_21_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_2_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_2_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_21_1' id='label_2_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $71,850\/year ($5,988\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_22'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_22'>\n\t\t\t<div class='gchoice gchoice_2_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Yes'  id='choice_2_22_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_22\"   \/>\n\t\t\t\t\t<label for='choice_2_22_0' id='label_2_22_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_2_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='No'  id='choice_2_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_22_1' id='label_2_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $76,800\/year ($6,400\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_23'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_23'>\n\t\t\t<div class='gchoice gchoice_2_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_2_23_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_23\"   \/>\n\t\t\t\t\t<label for='choice_2_23_0' id='label_2_23_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_2_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_2_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_23_1' id='label_2_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $81,750\/year ($6,813\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_24'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_24'>\n\t\t\t<div class='gchoice gchoice_2_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Yes'  id='choice_2_24_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_24\"   \/>\n\t\t\t\t\t<label for='choice_2_24_0' id='label_2_24_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_2_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='No'  id='choice_2_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_24_1' id='label_2_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $86,660\/year ($7,222\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_44'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_44'>\n\t\t\t<div class='gchoice gchoice_2_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_2_44_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_44\"   \/>\n\t\t\t\t\t<label for='choice_2_44_0' id='label_2_44_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_2_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_2_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_44_1' id='label_2_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is your household income (before taxes) less than or equal to $91,612\/year ($7,634\/month)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_45'>This includes all sources of income (including job income\/wages, pension, social security, disability, child support, and alimony) for all members of the household over the age of 18.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_45'>\n\t\t\t<div class='gchoice gchoice_2_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Yes'  id='choice_2_45_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_45\"   \/>\n\t\t\t\t\t<label for='choice_2_45_0' id='label_2_45_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_2_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='No'  id='choice_2_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_45_1' id='label_2_45_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><html><body><legend class=\"gfield_label gform-field-label\"><gftt-label class=\"gftt-label\">Do you currently receive any government assistance?<span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/gftt-label><i id=\"gftt-2_25\" class=\"gftt-icon gform-theme__no-reset--el\" tabindex=\"0\" data-placement=\"nw-alt\"><\/i><div class=\"gftt-content\" id=\"gftt-2_25-wrap\" role=\"tooltip\" aria-hidden=\"false\"><div id=\"gftt-2_25-content\" data-tid=\"gftt-2_25\" aria-hidden=\"false\">Types of government assistance may include: <br><br>\n\u2023 SNAP (Food Stamps)<br>\n\u2023 Free and Reduced School Lunch<br>\n\u2023 TANF (Temporary Assistance for Needy Families)<br>\n\u2023 Section 8\/Housing Choice Vouchers<br>\n\u2023 WIC Coupons (Women, Infants, and Children Supplemental Nutrition Program)<br>\n\u2023 Head Start Program<br>\n\u2023 CCDF Voucher (Childcare and Development Program)<br>\n\u2023 LITC (Low Income Tax Credit)<br>\n\u2023 Medicaid<br>\n\u2023 Medicaid CHIP Child Health Insurance<br>\n\u2023 Medicare Part D<br>\n\u2023 SSI (Social Security Insurance)<\/div><\/div><\/legend><div class=\"gfield_description\" id=\"gfield_description_2_25\">This helps us qualify you for certain programs. <br>For examples of types of government assistance, please hover over the question mark for more information.<\/div><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_2_25\">\n\t\t\t<div class=\"gchoice gchoice_2_25_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_25\" type=\"radio\" value=\"Yes\" id=\"choice_2_25_0\" onchange=\"gformToggleRadioOther( this )\" aria-describedby=\"gftt-2_25-wrap\">\n\t\t\t\t\t<label for=\"choice_2_25_0\" id=\"label_2_25_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_2_25_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_25\" type=\"radio\" value=\"No\" id=\"choice_2_25_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_2_25_1\" id=\"label_2_25_1\" class=\"gform-field-label gform-field-label--type-inline\">No<\/label>\n\t\t\t<\/div><\/div><\/div><\/body><\/html><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_36' 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_2_36' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_3' class='gform_page' data-js='page-field-id-36' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_3' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_2_40\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Additional Information<\/h3><\/div><fieldset id=\"field_2_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><html><body><legend class=\"gfield_label gform-field-label\"><gftt-label class=\"gftt-label\">Is your need for help related to economic factors of COVID-19?<span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/gftt-label><i id=\"gftt-2_27\" class=\"gftt-icon gform-theme__no-reset--el\" tabindex=\"0\" data-placement=\"nw-alt\"><\/i><div class=\"gftt-content\" id=\"gftt-2_27-wrap\" role=\"tooltip\" aria-hidden=\"false\"><div id=\"gftt-2_27-content\" data-tid=\"gftt-2_27\" aria-hidden=\"false\"><strong>Examples of COVID-related economic hardship include: <\/strong><br><br>\n\u2023 Job loss of household member due to business being affected<br>\n\u2023 Reduced hours of household member as a result of business being affected<br>\n\u2023 Place of employment closed due to business being affected<br>\n\u2023 More than a 10% increase in rent between 2021 and 2023<br>\n\u2023 More than a 20% increase in utilities between 2021 and 2023<br>\n\u2023 Increased household expenses (childcare, medical bills, food, etc.)<br>\n\u2023 Health issues as a result of COVID-19 factors<br>\n\u2023 Mental health issues as a result of COVID-19 factors<br>\n\u2023 Unstable employment<br>\n<br>Other hardship factors may apply<\/div><\/div><\/legend><div class=\"gfield_description\" id=\"gfield_description_2_27\">For examples of economic factors of COVID-19, please hover over the question mark for more information.<\/div><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_2_27\">\n\t\t\t<div class=\"gchoice gchoice_2_27_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_27\" type=\"radio\" value=\"Yes\" id=\"choice_2_27_0\" onchange=\"gformToggleRadioOther( this )\" aria-describedby=\"gftt-2_27-wrap\">\n\t\t\t\t\t<label for=\"choice_2_27_0\" id=\"label_2_27_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_2_27_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_27\" type=\"radio\" value=\"No\" id=\"choice_2_27_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_2_27_1\" id=\"label_2_27_1\" class=\"gform-field-label gform-field-label--type-inline\">No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_2_27_2\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_27\" type=\"radio\" value=\"Unsure\" id=\"choice_2_27_2\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_2_27_2\" id=\"label_2_27_2\" class=\"gform-field-label gform-field-label--type-inline\">Unsure<\/label>\n\t\t\t<\/div><\/div><\/div><\/body><\/html><\/fieldset><div id=\"field_2_28\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Contact Information<\/h3><\/div><fieldset id=\"field_2_29\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above 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\">(Obligatorio)<\/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_2_29'>\n                            \n                            <span id='input_2_29_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_29.3' id='input_2_29_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_29_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_29_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_29.6' id='input_2_29_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_29_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_30\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_30'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_30' id='input_2_30' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_31\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_31'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_31' id='input_2_31' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_2_32\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above 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\">(Obligatorio)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_2_32' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_32_1_container' >\n                                        <input type='text' name='input_32.1' id='input_2_32_1' value=''    aria-required='true'    \/>\n                                        <label for='input_2_32_1' id='input_2_32_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_2_32_2_container' >\n                                        <input type='text' name='input_32.2' id='input_2_32_2' value=''     aria-required='false'   \/>\n                                        <label for='input_2_32_2' id='input_2_32_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_32_3_container' >\n                                    <input type='text' name='input_32.3' id='input_2_32_3' value=''    aria-required='true'    \/>\n                                    <label for='input_2_32_3' id='input_2_32_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_32_4_container' >\n                                        <select name='input_32.4' id='input_2_32_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >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' >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='Islas Marianas del Norte' >Islas Marianas del Norte<\/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='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' selected='selected'>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_2_32_4' id='input_2_32_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_32_5_container' >\n                                    <input type='text' name='input_32.5' id='input_2_32_5' value=''    aria-required='true'    \/>\n                                    <label for='input_2_32_5' id='input_2_32_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_32.6' id='input_2_32_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_2_33\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What is the best time to reach you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_33'>Select all that apply<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_33'><div class='gchoice gchoice_2_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='Business hours (9:00 am - 5:00 pm)'  id='choice_2_33_1'   aria-describedby=\"gfield_description_2_33\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_33_1' id='label_2_33_1' class='gform-field-label gform-field-label--type-inline'>Business hours (9:00 am &#8211; 5:00 pm)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_33_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.2' type='checkbox'  value='After 5:00 pm'  id='choice_2_33_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_33_2' id='label_2_33_2' class='gform-field-label gform-field-label--type-inline'>After 5:00 pm<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_33_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.3' type='checkbox'  value='Weekends'  id='choice_2_33_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_33_3' id='label_2_33_3' class='gform-field-label gform-field-label--type-inline'>Weekends<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_33_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.4' type='checkbox'  value='Any time is good'  id='choice_2_33_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_33_4' id='label_2_33_4' class='gform-field-label gform-field-label--type-inline'>Any time is good<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_39\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_39.1' id='input_2_39_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_39_1' >I certify that the information I have provided is true and complete to the best of my knowledge.<\/label><input type='hidden' name='input_39.2' value='I certify that the information I have provided is true and complete to the best of my knowledge.' class='gform_hidden' \/><input type='hidden' name='input_39.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_2_47\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_47'>By typing my name below, I acknowledge and authorize Loudoun Cares to share the information provided with the agencies, partners, and personnel necessary to process my request for assistance.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_2_47' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_41\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label 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