cloud.benefitsapplication.com
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Submitted URL: https://alphatra.cx/tracker/662f0a86-5bee-4601-9123-9ec39aa34829?src=bap-zip&utm_source=bap-zip&postal_code=04281&pr...
Effective URL: https://cloud.benefitsapplication.com/?src=bap-zip&utm_source=bap-zip&postal_code=04281&program=LIHEAP&nx_clid=35025e17-ea87-4b2b-8192...
Submission: On February 28 via manual from US — Scanned from NL
Effective URL: https://cloud.benefitsapplication.com/?src=bap-zip&utm_source=bap-zip&postal_code=04281&program=LIHEAP&nx_clid=35025e17-ea87-4b2b-8192...
Submission: On February 28 via manual from US — Scanned from NL
Form analysis 1 forms found in the DOM
POST
<form method="POST" data-id="heyflow-form" id="calculate-your-benefits" novalidate="">
<section id="id-e9076bba" name="welcome-loader" data-type="user" class="undefined with-avatar navigated hidden" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-narrow" id="text-block-id-08dc6bd5">
<div class="rich-text" style="padding-top:40px; padding-bottom:20px;">
<h1>Final Eligibility Questions for <span style="color: var(--green)"><u><span class="variable-replace" data-variable="program">LIHEAP</span></u></span> - Let's Go!</h1>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-narrow" id="text-block-rich-text-24f7b548">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h4><span style="color: var(--grey)">Checking requirements in </span><span style="color: var(--grey)"><span class="variable-replace" data-variable="postal_code">04281</span></span></h4>
</div>
</div>
</div>
<div class="block" style="background-color:none;" data-blocktype="loader">
<div style="" class="block-content loader-block center inner-narrow" id="loader-block-id-3379cafa" data-id="id-3379cafa" data-timeout="2000" data-action="next"
data-options="{"blockStyle":"background-color:none;","redirectURL":"https://heyflow.app","destination":"screen-ffa9beda","type":"loader","timeout":"2000","target":"_self","paddingBottom":20,"name":"loader","action":"next","disabled":false,"paddingTop":20,"id":"id-3379cafa","class":"center&nbsp;inner-narrow"}">
<div style="padding-top:20px; padding-bottom:20px;">
<div id="id-3379cafa" class="circle-loader circle-loader-load-success">
<div class="circle-loader-checkmark draw"></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide has-value" id="id-cca4988e-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-cca4988e">src</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-cca4988e" data-type="input" data-label="src" data-variable="src" data-mask="" name="id-cca4988e" placeholder="" pattern="" maxlength="" data-trim="" autofocus="" autocomplete="off"
class="" data-initialized="true">
<div class="input-floating-label"><span>src</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-cca4988e">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide has-value" id="id-3485aa6e-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-3485aa6e">utm_source</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-3485aa6e" data-type="input" data-label="utm_source" data-variable="utm_source" data-mask="" name="id-3485aa6e" placeholder="" pattern="" maxlength="" data-trim="" autofocus=""
autocomplete="off" class="" data-initialized="true">
<div class="input-floating-label"><span>utm_source</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-3485aa6e">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide" id="id-8a8ece9a-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-8a8ece9a">laminLid</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-8a8ece9a" data-type="input" data-label="laminLid" data-variable="laminLid" data-mask="" name="id-8a8ece9a" placeholder="" pattern="" maxlength="" data-trim="" autofocus=""
autocomplete="off" class="" data-initialized="true">
<div class="input-floating-label"><span>laminLid</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-8a8ece9a">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide has-value" id="id-5d10f8f0-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-5d10f8f0">program</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-5d10f8f0" data-type="input" data-label="program" data-variable="program" data-mask="" name="id-5d10f8f0" placeholder="" pattern="" maxlength="" data-trim="" autofocus=""
autocomplete="off" class="" data-initialized="true">
<div class="input-floating-label"><span>program</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-5d10f8f0">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide has-value" id="id-0b15008b-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-0b15008b">nx_clid</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-0b15008b" data-type="input" data-label="nx_clid" data-variable="nx_clid" data-mask="" name="id-0b15008b" placeholder="" pattern="" maxlength="" data-trim="" autofocus=""
autocomplete="off" class="" data-initialized="true">
<div class="input-floating-label"><span>nx_clid</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-0b15008b">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide" id="id-d20c50e9-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-d20c50e9">msclkid</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-d20c50e9" data-type="input" data-label="msclkid" data-variable="msclkid" data-mask="" name="id-d20c50e9" placeholder="" pattern="" maxlength="" data-trim="" autofocus=""
autocomplete="off" class="" data-initialized="true">
<div class="input-floating-label"><span>msclkid</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-d20c50e9">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide has-value" id="id-22ef74d8-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-22ef74d8">disclaimer_variable</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-22ef74d8" data-type="input" data-label="disclaimer_variable" data-variable="disclaimer_variable" data-mask="" name="id-22ef74d8" placeholder="" pattern="" maxlength=""
value="nxv_form_disclaimer_benefitsapplication" data-trim="" autofocus="" autocomplete="off" class="" data-initialized="true">
<div class="input-floating-label"><span>disclaimer_variable</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-22ef74d8">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide has-value" id="id-ef9cca04-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-ef9cca04">brand</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-ef9cca04" data-type="input" data-label="brand" data-variable="brand" data-mask="" name="id-ef9cca04" placeholder="" pattern="" maxlength="" value="benefitsapplication.com"
data-trim="" autofocus="" autocomplete="off" class="" data-initialized="true">
<div class="input-floating-label"><span>brand</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-ef9cca04">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide" id="id-dc8c805c-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-dc8c805c">leadid_token</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-dc8c805c" data-type="input" data-label="leadid_token" data-variable="leadid_token" data-mask="" name="id-dc8c805c" placeholder="" pattern="" maxlength="" data-trim="" autofocus=""
autocomplete="off" class="" data-initialized="true">
<div class="input-floating-label"><span>leadid_token</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-dc8c805c">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide" id="id-41df6930-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-41df6930">s_src</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-41df6930" data-type="input" data-label="s_src" data-variable="s_src" data-mask="" name="id-41df6930" placeholder="" pattern="" maxlength="" data-trim="" autofocus=""
autocomplete="off" class="" data-initialized="true">
<div class="input-floating-label"><span>s_src</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-41df6930">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide" id="id-88d160a1-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-88d160a1">s_cid</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-88d160a1" data-type="input" data-label="s_cid" data-variable="s_cid" data-mask="" name="id-88d160a1" placeholder="" pattern="" maxlength="" data-trim="" autofocus=""
autocomplete="off" class="" data-initialized="true">
<div class="input-floating-label"><span>s_cid</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-88d160a1">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide" id="id-c71fa8f5-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-c71fa8f5">s_agid</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-c71fa8f5" data-type="input" data-label="s_agid" data-variable="s_agid" data-mask="" name="id-c71fa8f5" placeholder="" pattern="" maxlength="" data-trim="" autofocus=""
autocomplete="off" class="" data-initialized="true">
<div class="input-floating-label"><span>s_agid</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-c71fa8f5">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide" id="id-b7394813-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-b7394813">s_tid</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-b7394813" data-type="input" data-label="s_tid" data-variable="s_tid" data-mask="" name="id-b7394813" placeholder="" pattern="" maxlength="" data-trim="" autofocus=""
autocomplete="off" class="" data-initialized="true">
<div class="input-floating-label"><span>s_tid</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-b7394813">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide" id="id-cfec826e-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-cfec826e">s_mt</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-cfec826e" data-type="input" data-label="s_mt" data-variable="s_mt" data-mask="" name="id-cfec826e" placeholder="" pattern="" maxlength="" data-trim="" autofocus="" autocomplete="off"
class="" data-initialized="true">
<div class="input-floating-label"><span>s_mt</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-cfec826e">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide" id="id-3aa04427-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-3aa04427">s_n</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-3aa04427" data-type="input" data-label="s_n" data-variable="s_n" data-mask="" name="id-3aa04427" placeholder="" pattern="" maxlength="" data-trim="" autofocus="" autocomplete="off"
class="" data-initialized="true">
<div class="input-floating-label"><span>s_n</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-3aa04427">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide" id="id-13a607e3-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-13a607e3">s_d</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-13a607e3" data-type="input" data-label="s_d" data-variable="s_d" data-mask="" name="id-13a607e3" placeholder="" pattern="" maxlength="" data-trim="" autofocus="" autocomplete="off"
class="" data-initialized="true">
<div class="input-floating-label"><span>s_d</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-13a607e3">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide" id="id-b52c68e6-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-b52c68e6">s_adid</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-b52c68e6" data-type="input" data-label="s_adid" data-variable="s_adid" data-mask="" name="id-b52c68e6" placeholder="" pattern="" maxlength="" data-trim="" autofocus=""
autocomplete="off" class="" data-initialized="true">
<div class="input-floating-label"><span>s_adid</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-b52c68e6">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide" id="id-f0a7da06-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-f0a7da06">s_aid</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-f0a7da06" data-type="input" data-label="s_aid" data-variable="s_aid" data-mask="" name="id-f0a7da06" placeholder="" pattern="" maxlength="" data-trim="" autofocus=""
autocomplete="off" class="" data-initialized="true">
<div class="input-floating-label"><span>s_aid</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-f0a7da06">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide" id="id-dc95c495-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-dc95c495">s_pos</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-dc95c495" data-type="input" data-label="s_pos" data-variable="s_pos" data-mask="" name="id-dc95c495" placeholder="" pattern="" maxlength="" data-trim="" autofocus=""
autocomplete="off" class="" data-initialized="true">
<div class="input-floating-label"><span>s_pos</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-dc95c495">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide" id="id-bd25ae3a-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-bd25ae3a">s_plc</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-bd25ae3a" data-type="input" data-label="s_plc" data-variable="s_plc" data-mask="" name="id-bd25ae3a" placeholder="" pattern="" maxlength="" data-trim="" autofocus=""
autocomplete="off" class="" data-initialized="true">
<div class="input-floating-label"><span>s_plc</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-bd25ae3a">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav hide" id="id-0b5514e4-container">
<div style="padding-top:20px; padding-bottom:20px;"><label for="id-0b5514e4">s_k</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-0b5514e4" data-type="input" data-label="s_k" data-variable="s_k" data-mask="" name="id-0b5514e4" placeholder="" pattern="" maxlength="" data-trim="" autofocus="" autocomplete="off"
class="" data-initialized="true">
<div class="input-floating-label"><span>s_k</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-0b5514e4">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span></div>
</div>
</div>
</div>
</div>
</section>
<section id="start" name="welcome" data-type="user" class="with-avatar visible" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="elements-v2">
<div class="block-content elements-container elements-v2-container inner-full" data-type="nested-blocks">
<div class="container-style-plain" style="margin-top:10px; margin-right:0px; margin-bottom:10px; margin-left:0px; padding-top:10px; padding-right:20px; padding-bottom:10px; padding-left:20px;">
<div class="elements-container-inner inner-narrow" style="justify-content:normal; flex-direction:column; align-items:stretch;margin-left:auto;margin-right:auto;">
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-left" id="text-block-headline-b305619c">
<div class="rich-text" style="padding-top:15px; padding-bottom:20px;">
<h3><span style="color: var(--off-black)"><strong>Do you currently receive any government benefits?</strong></span></h3>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-b1da0501" data-align-siblings="" data-multiselect="">
<div style="padding-top:5px; padding-bottom:5px;">
<div class="multiple-choice-label" style="justify-content:flex-start;"><label class="block-label">If yes, please select all that apply:</label></div>
<div class="multiple-choice mc-collapse-list">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-59455fec" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">1</div><input type="checkbox" id="option-HdrFU0yGRTTC_2C0cDEih" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="current_benefit_list" name="id-b1da0501"
data-variable="current_benefit_list" value="option-HdrFU0yGRTTC_2C0cDEih" data-conditional="true" data-answer="Supplemental Security Income (SSI)" data-destination="id-59455fec" data-priority="0"
data-tracking-listener="true">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Supplemental Security Income (SSI)</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-59455fec" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">2</div><input type="checkbox" id="id-f18664bb" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="current_benefit_list" name="id-b1da0501"
data-variable="current_benefit_list" value="id-f18664bb" data-conditional="true" data-answer="Section 8 Housing" data-destination="id-59455fec" data-priority="0" data-tracking-listener="true">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Section 8 Housing</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-59455fec" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">3</div><input type="checkbox" id="id-d6b75cc3" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="current_benefit_list" name="id-b1da0501"
data-variable="current_benefit_list" value="id-d6b75cc3" data-conditional="true" data-answer="SNAP (Food Stamps)" data-destination="id-59455fec" data-priority="0" data-tracking-listener="true">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">SNAP (Food Stamps)</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-59455fec" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">4</div><input type="checkbox" id="id-3fab8f80" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="current_benefit_list" name="id-b1da0501"
data-variable="current_benefit_list" value="id-3fab8f80" data-conditional="true" data-answer="Medicare" data-destination="id-59455fec" data-priority="0" data-tracking-listener="true">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
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</svg></span></div>
<div class="label-container">
<div class="label">Medicare</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option multiple-choice-option-is-input" hey-nextscreen="id-59455fec" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">5</div><input type="checkbox" id="option-qaCXB4VMRKMPxtFTsj38K" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="current_benefit_list" name="id-b1da0501"
data-variable="current_benefit_list" value="option-qaCXB4VMRKMPxtFTsj38K" data-conditional="true" data-answer="Other (please specify)" data-destination="id-59455fec" data-priority="0" data-tracking-listener="true">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
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<div class="input-container">
<div class="input"><input onfocus="window.heyflow['calculate-your-benefits'].flowQuery('#option-qaCXB4VMRKMPxtFTsj38K').checked = true;" class="multiple-choice-option-input" id="option-qaCXB4VMRKMPxtFTsj38K-input"
data-type="input" name="option-qaCXB4VMRKMPxtFTsj38K-input" placeholder="Other (please specify)" data-label="current_benefit_list [Other (please specify)]"></div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-84940580" data-align-siblings="" data-multiselect="">
<div style="padding-top:0px; padding-bottom:10px;">
<div class="multiple-choice mc-list">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-59455fec" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['calculate-your-benefits'].navigation.navigate('go','id-59455fec');" type="checkbox" id="id-9815bce4" data-tracking="true" data-event-name=""
data-type="multiple-choice" data-label="no_current_benefits" name="id-84940580" data-variable="no_current_benefits" value="id-9815bce4" data-conditional="true" data-answer="None" data-destination="id-59455fec"
data-priority="0" data-tracking-listener="true">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
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<div class="label-container">
<div class="label">None</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
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<div style="padding-top:10px; padding-bottom:40px;"><button id="button-c22d6772" class="generic-button continue large"
onclick="window.heyflow['calculate-your-benefits'].buttonClick(this, 'next', '', '{"containerClass":"inner-narrow","nextAction":"next","label":"CONTINUE","type":"generic-button","tracking":true,"paddingBottom":"40","name":"button-continue","action":"next","contentClass":"align-space-between","paddingTop":"10","id":"button-c22d6772","class":"continue&nbsp;large"}')">
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</svg></div>
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<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
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<div class="label-container"><span class="label">CONTINUE</span></div><span class="graphic"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
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<polyline points="144 56 216 128 144 200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span>
</div>
</button></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="background-color:none;" data-blocktype="elements-v2">
<div class="block-content elements-container elements-v2-container inner-narrow" data-type="nested-blocks">
<div class="container-style-1" style="margin-top:25px; margin-right:10px; margin-bottom:25px; margin-left:10px; padding-top:0px; padding-bottom:0px;">
<div class="elements-container-inner inner-narrow" style="justify-content:normal;align-items:center;flex-direction:row;margin-left:auto;margin-right:auto;">
<div class="block" style="background-color:none;" data-blocktype="rich-text">
<div class="block-content text-block inner-mid align-left" id="text-block-id-c30cdc22">
<div class="rich-text" style="padding-top:25px; padding-right:25px; padding-bottom:25px; padding-left:25px;">
<h5><span style="color: var(--dark-grey)"><strong>FACT:</strong></span><span style="color: var(--dark-grey)"> The USA spends around TWO TRILLION dollars each year on programs like </span><span
style="color: var(--secondary)"><strong><span class="variable-replace" data-variable="program">LIHEAP</span></strong></span><span style="color: var(--dark-grey)"> to help people like you and me!</span></h5>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-59455fec" name="ssd-receiving-filter-1" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="elements-v2">
<div class="block-content elements-container elements-v2-container inner-full" data-type="nested-blocks">
<div class="container-style-plain" style="margin-top:10px; margin-right:10px; margin-bottom:10px; margin-left:0px; padding-top:10px; padding-right:20px; padding-bottom:10px; padding-left:20px;">
<div class="elements-container-inner inner-narrow" style="justify-content:normal; flex-direction:column; align-items:stretch;margin-left:auto;margin-right:auto;">
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-left" id="text-block-id-efef0931">
<div class="rich-text" style="padding-top:30px; padding-bottom:20px;">
<h3><span style="color: var(--off-black)"><strong>Do you currently receive </strong></span><span style="color: var(--off-black)"><u><strong>Social Security Disability</strong></u></span><span style="color: var(--off-black)"><strong>
benefits?</strong></span></h3>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-0e8511ff" data-align-siblings="">
<div style="padding-top:5px; padding-bottom:20px;">
<div class="multiple-choice mc-list">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-e751b024" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['calculate-your-benefits'].navigation.navigate('go','screen-e751b024');" type="radio" id="id-07f402d4" data-tracking="true" data-event-name=""
data-type="multiple-choice" data-label="receiving_benefits" name="id-0e8511ff" data-variable="receiving_benefits" value="id-07f402d4" data-conditional="true" data-answer="No" data-destination="screen-e751b024"
data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-e3f3ba47" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['calculate-your-benefits'].navigation.navigate('go','id-e3f3ba47');" type="radio" id="id-ad5bf111" data-tracking="true" data-event-name=""
data-type="multiple-choice" data-label="receiving_benefits" name="id-0e8511ff" data-variable="receiving_benefits" value="id-ad5bf111" data-conditional="true" data-answer="Yes" data-destination="id-e3f3ba47"
data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="screen-e751b024" name="ssd-oow-filter-2" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-left" id="text-block-id-42a77204">
<div class="rich-text" style="padding-top:30px; padding-bottom:20px;">
<h3><span style="color: var(--off-black)"><strong>Do you expect to be </strong></span><span style="color: var(--off-black)"><u><strong>out of work for at least a year</strong></u></span><span style="color: var(--off-black)"><strong> due to
your health?</strong></span></h3>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-mc-81b21527" data-align-siblings="">
<div style="padding-top:5px; padding-bottom:20px;">
<div class="multiple-choice-label" style="justify-content:center;"><label class="block-label">We can help you apply, appeal, or maximize your disability benefits.</label></div>
<div class="multiple-choice mc-list">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-b2320c65" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['calculate-your-benefits'].navigation.navigate('go','id-b2320c65');" type="radio" id="mco-1def91ca" data-tracking="true" data-event-name=""
data-type="multiple-choice" data-label="affected_work" name="mc-81b21527" data-variable="affected_work" value="mco-1def91ca" data-conditional="true" data-answer="Yes" required="" data-destination="id-b2320c65" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-e3f3ba47" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['calculate-your-benefits'].navigation.navigate('go','id-e3f3ba47');" type="radio" id="mco-163cf30e" data-tracking="true" data-event-name=""
data-type="multiple-choice" data-label="affected_work" name="mc-81b21527" data-variable="affected_work" value="mco-163cf30e" data-conditional="true" data-answer="No" required="" data-destination="id-e3f3ba47" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="background-color:none;" data-blocktype="elements-v2">
<div class="block-content elements-container elements-v2-container inner-narrow" data-type="nested-blocks">
<div class="container-style-1" style="margin-top:25px; margin-right:10px; margin-bottom:25px; margin-left:10px; padding-top:0px; padding-bottom:0px;">
<div class="elements-container-inner inner-narrow" style="justify-content:normal;align-items:center;flex-direction:row;margin-left:auto;margin-right:auto;">
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<div class="block-content text-block inner-mid align-left" id="text-block-id-61b192d6">
<div class="rich-text" style="padding-top:25px; padding-right:25px; padding-bottom:25px; padding-left:25px;">
<h5><span style="color: var(--dark-grey)"><strong>FACT:</strong></span><span style="color: var(--dark-grey)"> If you are approved for SSDI benefits in 2023, you could receive up to </span><span
style="color: var(--dark-grey)"><strong>$3,148/month</strong></span><span style="color: var(--dark-grey)"> to help cover your living expenses and provide financial stability.</span></h5>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
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onclick="window.heyflow['calculate-your-benefits'].buttonClick(this, 'goBack', '', '{"containerClass":"inner-narrow","nextAction":"next","label":"BACK","type":"generic-button","tracking":true,"paddingBottom":20,"name":"button-link","action":"goBack","contentClass":"align-space-between","id":"id-b0b617ce","paddingTop":20,"class":"link&nbsp;medium&nbsp;collapse&nbsp;align-center"}')">
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
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<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
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</path>
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<section id="id-b2320c65" name="disability-full-form" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
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<div class="block-content text-block inner-narrow align-left" id="text-block-id-3363bbd4">
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<h3><span style="color: var(--off-black)"><strong>Have you had a full-time job within the past 5 years?</strong></span></h3>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-1573679e" data-align-siblings="">
<div style="padding-top:5px; padding-bottom:0px;">
<div class="multiple-choice mc-list">
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<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">1</div><input type="radio" id="id-4b68cc43" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="worked_5_of_10" name="id-1573679e" data-variable="worked_5_of_10"
value="id-4b68cc43" data-answer="Yes" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">2</div><input type="radio" id="id-6015732d" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="worked_5_of_10" name="id-1573679e" data-variable="worked_5_of_10"
value="id-6015732d" data-answer="No" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-left" id="text-block-id-c0dd0fa4">
<div class="rich-text" style="padding-top:30px; padding-bottom:20px;">
<h3><span style="color: var(--off-black)"><strong>Are you actively working with a disability advocate or attorney?</strong></span></h3>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-026ff4ba" data-align-siblings="">
<div style="padding-top:5px; padding-bottom:20px;">
<div class="multiple-choice mc-list">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">1</div><input type="radio" id="id-43a03d14" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="current_advocate" name="id-026ff4ba" data-variable="current_advocate"
value="id-43a03d14" data-answer="No" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">2</div><input type="radio" id="id-64983861" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="current_advocate" name="id-026ff4ba" data-variable="current_advocate"
value="id-64983861" data-answer="Yes" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-left" id="text-block-id-311c974b">
<div class="rich-text" style="padding-top:0px; padding-bottom:20px;">
<h3><span style="color: var(--off-black)"><strong>What describes your situation?</strong></span></h3>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-36dd624d" data-align-siblings="" data-multiselect="">
<div style="padding-top:5px; padding-bottom:15px;">
<div class="multiple-choice-label" style="justify-content:center;"><label class="block-label">Select any that apply:</label></div>
<div class="multiple-choice mc-flex">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">1</div><input type="checkbox" id="id-f5016cd3" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="id-f5016cd3" data-answer="Cancer" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Cancer</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">2</div><input type="checkbox" id="id-7b65461f" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="id-7b65461f" data-answer="Multiple Medical Issues" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Multiple Medical Issues</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">3</div><input type="checkbox" id="option-feYTlwqCyWzYzKRFBZ6qp" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="option-feYTlwqCyWzYzKRFBZ6qp" data-answer="Struggle Walking" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Struggle Walking</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">4</div><input type="checkbox" id="option-EBJeYz3Goo6w89snEpUeF" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="option-EBJeYz3Goo6w89snEpUeF" data-answer="Knee Pain" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Knee Pain</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">5</div><input type="checkbox" id="option-rCXc8c4TUfejaggvSxZ5t" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="option-rCXc8c4TUfejaggvSxZ5t" data-answer="Back Pain" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Back Pain</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">6</div><input type="checkbox" id="option-wM3EYyRcBHuRhRvt8f1dS" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="option-wM3EYyRcBHuRhRvt8f1dS" data-answer="Need Help Applying" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Need Help Applying</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">7</div><input type="checkbox" id="option-C4RxOptJ0PBjRqY0VbVe2" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="option-C4RxOptJ0PBjRqY0VbVe2" data-answer="Hearing Issues" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Hearing Issues</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">8</div><input type="checkbox" id="option-m-ISOinfidQfVaPjiLH39" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="option-m-ISOinfidQfVaPjiLH39" data-answer="Heart Disease" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Heart Disease</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">9</div><input type="checkbox" id="option-5HiUSGiUgP1B2YzPzmttS" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="option-5HiUSGiUgP1B2YzPzmttS" data-answer="Arthritis" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Arthritis</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">10</div><input type="checkbox" id="option-f5_G28SW4JgJD5u5a91Lu" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="option-f5_G28SW4JgJD5u5a91Lu" data-answer="Vision / Blindness" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Vision / Blindness</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">11</div><input type="checkbox" id="option-BufFhw876S3g2Sg9P1zZv" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="option-BufFhw876S3g2Sg9P1zZv" data-answer="In An Accident" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">In An Accident</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">12</div><input type="checkbox" id="option-Zy_nNviwjZflTAODdiJEc" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="option-Zy_nNviwjZflTAODdiJEc" data-answer="Mental Health" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Mental Health</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">13</div><input type="checkbox" id="option-qU466Pkbja1TkY5spHCdJ" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="option-qU466Pkbja1TkY5spHCdJ" data-answer="PTSD" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">PTSD</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">14</div><input type="checkbox" id="option-ja222mJttEnZstnNSLlOU" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="option-ja222mJttEnZstnNSLlOU" data-answer="Depression" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Depression</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">15</div><input type="checkbox" id="option-N3DIb5Fen-PmC__9N5i9Q" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="option-N3DIb5Fen-PmC__9N5i9Q" data-answer="Physical Limitations" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Physical Limitations</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">16</div><input type="checkbox" id="option-KQ0aeidGBd4KPVJeGmg1o" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="option-KQ0aeidGBd4KPVJeGmg1o" data-answer="SSD Appeal" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">SSD Appeal</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">17</div><input type="checkbox" id="option-_8PXVA2Th9mStnVLPQ6ap" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="option-_8PXVA2Th9mStnVLPQ6ap" data-answer="Drug Addiction" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Drug Addiction</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">18</div><input type="checkbox" id="option-fABs5l-rjjbLPf-P9qdG0" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="option-fABs5l-rjjbLPf-P9qdG0" data-answer="Learning Disability" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Learning Disability</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">19</div><input type="checkbox" id="option-bRnHolYAleWeEU-ZGfQh8" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="option-bRnHolYAleWeEU-ZGfQh8" data-answer="Debt Help" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Debt Help</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">20</div><input type="checkbox" id="option-3IIA_C2PC_ZfJ14sKuVT8" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="disability_description" name="id-36dd624d"
data-variable="disability_description" value="option-3IIA_C2PC_ZfJ14sKuVT8" data-answer="Call me to Discuss" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
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<div class="label">Call me to Discuss</div>
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<div></div>
</label></div>
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</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-left" id="text-block-id-59e47d2a">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h3><span style="color: var(--off-black)"><strong>Are you seeing a doctor or taking prescription medication to help with your situation?</strong></span></h3>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-1c464e99" data-align-siblings="">
<div style="padding-top:5px; padding-bottom:10px;">
<div class="multiple-choice mc-list">
<div class="multiple-choice-inner" style="justify-content:center;">
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<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">1</div><input type="radio" id="id-54aaed2f" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="current_dr_or_script" name="id-1c464e99" data-variable="current_dr_or_script"
value="id-54aaed2f" data-answer="Yes" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">2</div><input type="radio" id="id-ed3e7570" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="current_dr_or_script" name="id-1c464e99" data-variable="current_dr_or_script"
value="id-ed3e7570" data-answer="No" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-left" id="text-block-id-1922f19b">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h3><span style="color: var(--off-black)"><strong>Have you or your spouse served in the US Military? 🇺🇸</strong></span></h3>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-360d9eb7" data-align-siblings="">
<div style="padding-top:5px; padding-bottom:10px;">
<div class="multiple-choice mc-list">
<div class="multiple-choice-inner" style="justify-content:center;">
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<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">1</div><input type="radio" id="id-a7764ab4" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="is_veteran" name="id-360d9eb7" data-variable="is_veteran" value="id-a7764ab4"
data-answer="Yes" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">2</div><input type="radio" id="id-984858cc" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="is_veteran" name="id-360d9eb7" data-variable="is_veteran" value="id-984858cc"
data-answer="No" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-left" id="text-block-id-9747b755">
<div class="rich-text" style="padding-top:30px; padding-bottom:20px;">
<h3><span style="color: var(--off-black)"><strong>Do you earn less than $1,000 a month?</strong></span></h3>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-f8a29fec" data-align-siblings="">
<div style="padding-top:5px; padding-bottom:10px;">
<div class="multiple-choice mc-list">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">1</div><input type="radio" id="id-f45f5ea2" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="earning_less_than_1000" name="id-f8a29fec"
data-variable="earning_less_than_1000" value="id-f45f5ea2" data-answer="Yes" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">2</div><input type="radio" id="id-b6957f82" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="earning_less_than_1000" name="id-f8a29fec"
data-variable="earning_less_than_1000" value="id-b6957f82" data-answer="No" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="generic-button">
<div class="block-content generic-button-block inner-narrow" id="generic-button-block-id-d7de6882">
<div style="padding-top:10px; padding-bottom:40px;"><button id="id-d7de6882" class="generic-button continue large"
onclick="window.heyflow['calculate-your-benefits'].buttonClick(this, 'next', '', '{"containerClass":"inner-narrow","icon":null,"label":"CONTINUE","nextAction":"next","type":"generic-button","filename":null,"paddingBottom":"40","name":"button-continue","contentClass":"align-center","action":"next","id":"id-d7de6882","paddingTop":"10","class":"continue&nbsp;large"}')">
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<div class="label-container"><span class="label">CONTINUE</span></div>
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<div style="padding-top:20px; padding-bottom:20px;"><button id="id-323d880a" class="generic-button link medium collapse align-center"
onclick="window.heyflow['calculate-your-benefits'].buttonClick(this, 'goBack', '', '{"containerClass":"inner-narrow","label":"BACK","nextAction":"next","type":"generic-button","tracking":true,"paddingBottom":20,"name":"button-link","action":"goBack","contentClass":"align-space-between","id":"id-323d880a","paddingTop":20,"class":"link&nbsp;medium&nbsp;collapse&nbsp;align-center"}')">
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</section>
<section id="id-e3f3ba47" name="injuries" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="elements-v2">
<div class="block-content elements-container elements-v2-container inner-full" data-type="nested-blocks">
<div class="container-style-plain" style="margin-top:10px; margin-right:10px; margin-bottom:0px; margin-left:0px; padding-top:10px; padding-right:20px; padding-bottom:10px; padding-left:20px;">
<div class="elements-container-inner inner-narrow" style="justify-content:normal; flex-direction:column; align-items:stretch;margin-left:auto;margin-right:auto;">
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-center" id="text-block-id-b51f2dc0">
<div class="rich-text" style="padding-top:30px; padding-bottom:5px;">
<h3><span style="color: var(--off-black)"><strong>Have you or a loved one been injured by one of the following, within 2 years?</strong></span></h3>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-41cccd8c" data-align-siblings="" data-multiselect="">
<div style="padding-top:5px; padding-bottom:5px;">
<div class="multiple-choice-label" style="justify-content:center;"><label class="block-label">Select any that apply:</label></div>
<div class="multiple-choice mc-flex">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">1</div><input type="checkbox" id="id-af500baf" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="accident_type" name="id-41cccd8c" data-variable="accident_type"
value="id-af500baf" data-answer="Auto Accident" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Auto Accident</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">2</div><input type="checkbox" id="id-94ad1ffa" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="accident_type" name="id-41cccd8c" data-variable="accident_type"
value="id-94ad1ffa" data-answer="Work Injury" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Work Injury</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">3</div><input type="checkbox" id="id-a18a2008" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="accident_type" name="id-41cccd8c" data-variable="accident_type"
value="id-a18a2008" data-answer="Medical Malpractice" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Medical Malpractice</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">4</div><input type="checkbox" id="id-41beb7a9" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="accident_type" name="id-41cccd8c" data-variable="accident_type"
value="id-41beb7a9" data-answer="Slip and Fall" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Slip & Fall</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">5</div><input type="checkbox" id="id-5f27e28d" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="accident_type" name="id-41cccd8c" data-variable="accident_type"
value="id-5f27e28d" data-answer="Other Injury" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Other Injury</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">6</div><input type="checkbox" id="option-brjYfWfKvUr0QygWeCzvG" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="accident_type" name="id-41cccd8c"
data-variable="accident_type" value="option-brjYfWfKvUr0QygWeCzvG" data-answer="Does Not Apply" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Does Not Apply</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="elements-v2">
<div class="block-content elements-container elements-v2-container inner-full" data-type="nested-blocks">
<div class="container-style-plain" style="margin-top:10px; margin-right:10px; margin-bottom:0px; margin-left:0px; padding-top:10px; padding-right:20px; padding-bottom:10px; padding-left:20px;">
<div class="elements-container-inner inner-narrow" style="justify-content:normal; flex-direction:column; align-items:stretch;margin-left:auto;margin-right:auto;">
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-center" id="text-block-id-55b76441">
<div class="rich-text" style="padding-top:10px; padding-bottom:5px;">
<h3><span style="color: var(--off-black)"><strong>Have you or a loved one been exposed to any of the following:</strong></span></h3>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-b910dd70" data-align-siblings="" data-multiselect="">
<div style="padding-top:5px; padding-bottom:20px;">
<div class="multiple-choice-label" style="justify-content:center;"><label class="block-label">Select any that apply:</label></div>
<div class="multiple-choice mc-flex">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-9523fc70" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">1</div><input type="checkbox" id="id-195c4a76" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="tort_injury_type" name="id-b910dd70" data-variable="tort_injury_type"
value="id-195c4a76" data-answer="Hernia Mesh Implant" data-destination="id-9523fc70" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
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</svg></span></div>
<div class="label-container">
<div class="label">Hernia Mesh Implant</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-9523fc70" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">2</div><input type="checkbox" id="id-ac2b5925" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="tort_injury_type" name="id-b910dd70" data-variable="tort_injury_type"
value="id-ac2b5925" data-answer="Talcum (Baby Powder) Use" data-destination="id-9523fc70" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
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</svg></span></div>
<div class="label-container">
<div class="label">Talcum (Baby Powder) Use</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-9523fc70" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">3</div><input type="checkbox" id="option-gJZ5l8mF57ywhFzKW_P7X" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="tort_injury_type" name="id-b910dd70"
data-variable="tort_injury_type" value="option-gJZ5l8mF57ywhFzKW_P7X" data-answer="Roundup Weed Killer" data-destination="id-9523fc70" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
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</svg></span></div>
<div class="label-container">
<div class="label">Roundup Weed Killer</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-9523fc70" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">4</div><input type="checkbox" id="option-unmlaRdDEwj0rmvpfBLuo" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="tort_injury_type" name="id-b910dd70"
data-variable="tort_injury_type" value="option-unmlaRdDEwj0rmvpfBLuo" data-answer="3M Combat Ear Plugs" data-destination="id-9523fc70" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
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</svg></span></div>
<div class="label-container">
<div class="label">3M Combat Ear Plugs</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-9523fc70" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">5</div><input type="checkbox" id="option-7JvnEsMpetIkMlrxR1UnM" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="tort_injury_type" name="id-b910dd70"
data-variable="tort_injury_type" value="option-7JvnEsMpetIkMlrxR1UnM" data-answer="Firefighter Foam Exposure" data-destination="id-9523fc70" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
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</svg></span></div>
<div class="label-container">
<div class="label">Firefighter Foam Exposure</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-9523fc70" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">6</div><input type="checkbox" id="option-_cwCtBcwv3LSS7mVH4vx-" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="tort_injury_type" name="id-b910dd70"
data-variable="tort_injury_type" value="option-_cwCtBcwv3LSS7mVH4vx-" data-answer="Toxic Premature Baby Formula" data-destination="id-9523fc70" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Toxic Premature Baby Formula</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-9523fc70" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">7</div><input type="checkbox" id="option-4YOVtSUbM76wVce3akNoD" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="tort_injury_type" name="id-b910dd70"
data-variable="tort_injury_type" value="option-4YOVtSUbM76wVce3akNoD" data-answer="Camp Lejeune Water Contamination" data-destination="id-9523fc70" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Camp Lejeune Water Contamination</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-9523fc70" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">8</div><input type="checkbox" id="option-Ap2etQzohzW0xm-kg9PjX" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="tort_injury_type" name="id-b910dd70"
data-variable="tort_injury_type" value="option-Ap2etQzohzW0xm-kg9PjX" data-answer="Paraquat Weed Killer" data-destination="id-9523fc70" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Paraquat Weed Killer</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-9523fc70" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">9</div><input type="checkbox" id="option-iJBQyd3FcHegR1v3rpRwl" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="tort_injury_type" name="id-b910dd70"
data-variable="tort_injury_type" value="option-iJBQyd3FcHegR1v3rpRwl" data-answer="Hair Relaxer" data-destination="id-9523fc70" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
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</svg></span></div>
<div class="label-container">
<div class="label">Hair Relaxer</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-9523fc70" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">10</div><input type="checkbox" id="option-m0nUMcHzq2hqroWjIMVlf" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="tort_injury_type" name="id-b910dd70"
data-variable="tort_injury_type" value="option-m0nUMcHzq2hqroWjIMVlf" data-answer="Does Not Apply" data-destination="id-9523fc70" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Does Not Apply</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
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<section id="id-7c92f0e7" name="debt-amount" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="elements-v2">
<div class="block-content elements-container elements-v2-container inner-full" data-type="nested-blocks">
<div class="container-style-plain" style="margin-top:10px; margin-right:10px; margin-bottom:10px; margin-left:0px; padding-top:10px; padding-right:20px; padding-bottom:10px; padding-left:20px;">
<div class="elements-container-inner inner-narrow" style="justify-content:normal; flex-direction:column; align-items:stretch;margin-left:auto;margin-right:auto;">
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-left" id="text-block-id-77253d9f">
<div class="rich-text" style="padding-top:30px; padding-bottom:20px;">
<h3><span style="color: var(--off-black)"><strong>What is your current household credit card debt amount?</strong></span></h3>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-bf8a9507" data-align-siblings="">
<div style="padding-top:5px; padding-bottom:20px;">
<div class="multiple-choice-label" style="justify-content:center;"><label class="block-label">We can show you options to eliminate or consolidate your debt.</label></div>
<div class="multiple-choice mc-list">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['calculate-your-benefits'].navigation.navigate('next','');" type="radio" id="id-c9f1cf5d" data-tracking="true" data-event-name=""
data-type="multiple-choice" data-label="debt_amount" name="id-bf8a9507" data-variable="debt_amount" value="id-c9f1cf5d" data-answer="More than $50,000" data-destination="next" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">More than $50,000</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['calculate-your-benefits'].navigation.navigate('next','');" type="radio" id="id-49e5eca4" data-tracking="true" data-event-name=""
data-type="multiple-choice" data-label="debt_amount" name="id-bf8a9507" data-variable="debt_amount" value="id-49e5eca4" data-answer="Around $20,000" data-destination="next" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Around $20,000</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">3</div><input onclick="window.heyflow['calculate-your-benefits'].navigation.navigate('next','');" type="radio" id="id-4dfdc707" data-tracking="true" data-event-name=""
data-type="multiple-choice" data-label="debt_amount" name="id-bf8a9507" data-variable="debt_amount" value="id-4dfdc707" data-answer="Around $15,000" data-destination="next" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Around $15,000</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">4</div><input onclick="window.heyflow['calculate-your-benefits'].navigation.navigate('next','');" type="radio" id="id-a9b06904" data-tracking="true" data-event-name=""
data-type="multiple-choice" data-label="debt_amount" name="id-bf8a9507" data-variable="debt_amount" value="id-a9b06904" data-answer="Around $10,000" data-destination="next" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Around $10,000</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">5</div><input onclick="window.heyflow['calculate-your-benefits'].navigation.navigate('next','');" type="radio" id="id-7a5c5b2c" data-tracking="true" data-event-name=""
data-type="multiple-choice" data-label="debt_amount" name="id-bf8a9507" data-variable="debt_amount" value="id-7a5c5b2c" data-answer="Around $5,000" data-destination="next" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Around $5,000</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-210f5ced" name="debt-description" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="elements-v2">
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<div class="block-content text-block inner-narrow align-center" id="text-block-id-551c2918">
<div class="rich-text" style="padding-top:30px; padding-bottom:5px;">
<h3><span style="color: var(--off-black)"><strong>Describe your debt situation:</strong></span></h3>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-98ba3389" data-align-siblings="" data-multiselect="">
<div style="padding-top:5px; padding-bottom:5px;">
<div class="multiple-choice-label" style="justify-content:center;"><label class="block-label">Select any that apply:</label></div>
<div class="multiple-choice mc-flex">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">1</div><input type="checkbox" id="option-IVWekGeG8a5STHdxChJxg" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="debt_description" name="id-98ba3389"
data-variable="debt_description" value="option-IVWekGeG8a5STHdxChJxg" data-answer="Behind on payments" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Behind on payments</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">2</div><input type="checkbox" id="option-9oWdS7NCZDsjScY1DS9QD" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="debt_description" name="id-98ba3389"
data-variable="debt_description" value="option-9oWdS7NCZDsjScY1DS9QD" data-answer="Can't Make Future Payments" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Can't Make Future Payments</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">3</div><input type="checkbox" id="option-1jpVLBTQ3nR_kUwQHfrIM" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="debt_description" name="id-98ba3389"
data-variable="debt_description" value="option-1jpVLBTQ3nR_kUwQHfrIM" data-answer="Need Help Reducing Payments" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
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</svg></span></div>
<div class="label-container">
<div class="label">Need Help Reducing Payments</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">4</div><input type="checkbox" id="option-ArX1py64kRqg1BxvAp1yC" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="debt_description" name="id-98ba3389"
data-variable="debt_description" value="option-ArX1py64kRqg1BxvAp1yC" data-answer="Bankruptcy Help" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
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</svg></span></div>
<div class="label-container">
<div class="label">Bankruptcy Help</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">5</div><input type="checkbox" id="option-TOiW0B0HswhxevVxRe_KX" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="debt_description" name="id-98ba3389"
data-variable="debt_description" value="option-TOiW0B0HswhxevVxRe_KX" data-answer="Tax debt" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Tax debt</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">6</div><input type="checkbox" id="option-fRnVhEb4JpvBWtE9OMtNI" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="debt_description" name="id-98ba3389"
data-variable="debt_description" value="option-fRnVhEb4JpvBWtE9OMtNI" data-answer="Fixed Income. Need Debt Reduction." required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Fixed Income. Need Debt Reduction.</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">7</div><input type="checkbox" id="option-VyXG9QVNWTgsKkOajcBnr" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="debt_description" name="id-98ba3389"
data-variable="debt_description" value="option-VyXG9QVNWTgsKkOajcBnr" data-answer="Call Me to Discuss" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container checkbox-selector"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span></div>
<div class="label-container">
<div class="label">Call Me to Discuss</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="elements-v2">
<div class="block-content elements-container elements-v2-container inner-full" data-type="nested-blocks">
<div class="container-style-plain" style="margin-top:10px; margin-right:10px; margin-bottom:0px; margin-left:0px; padding-top:10px; padding-right:20px; padding-bottom:10px; padding-left:20px;">
<div class="elements-container-inner inner-mid" style="justify-content:normal; flex-direction:column; align-items:stretch;margin-left:auto;margin-right:auto;">
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-center" id="text-block-id-eeeaf0c7">
<div class="rich-text" style="padding-top:10px; padding-bottom:5px;">
<h3><span style="color: var(--off-black)"><strong>Estimate the value of your assets </strong></span></h3>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-6a4db7e9" data-align-siblings="">
<div style="padding-top:5px; padding-bottom:20px;">
<div class="multiple-choice-label" style="justify-content:center;"><label class="block-label">(Home + Car + Cash + Investments)</label></div>
<div class="multiple-choice mc-list">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-9523fc70" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">1</div><input type="radio" id="id-1f095b55" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="personal_asset_amount" name="id-6a4db7e9"
data-variable="personal_asset_amount" value="id-1f095b55" data-answer="Less than $50,000" required="" data-destination="id-9523fc70" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Less than $50,000</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-9523fc70" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">2</div><input type="radio" id="id-9e6204f6" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="personal_asset_amount" name="id-6a4db7e9"
data-variable="personal_asset_amount" value="id-9e6204f6" data-answer="More than $50,000" required="" data-destination="id-9523fc70" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">More than $50,000</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="generic-button">
<div class="block-content generic-button-block inner-narrow" id="generic-button-block-id-94919c9d">
<div style="padding-top:10px; padding-bottom:40px;"><button id="id-94919c9d" class="generic-button continue large"
onclick="window.heyflow['calculate-your-benefits'].buttonClick(this, 'next', '', '{"containerClass":"inner-narrow","icon":null,"label":"CONTINUE","nextAction":"next","type":"generic-button","filename":null,"paddingBottom":"40","name":"button-continue","contentClass":"align-center","action":"next","id":"id-94919c9d","paddingTop":"10","class":"continue&nbsp;large"}')">
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
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<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
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</path>
</svg></div>
</div>
<div class="content align-center">
<div class="label-container"><span class="label">CONTINUE</span></div>
</div>
</button></div>
</div>
</div>
</section>
<section id="id-9523fc70" name="monthly-income" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="elements-v2">
<div class="block-content elements-container elements-v2-container inner-full" data-type="nested-blocks">
<div class="container-style-plain" style="margin-top:10px; margin-right:10px; margin-bottom:10px; margin-left:0px; padding-top:10px; padding-right:20px; padding-bottom:10px; padding-left:20px;">
<div class="elements-container-inner inner-narrow" style="justify-content:normal; flex-direction:column; align-items:stretch;margin-left:auto;margin-right:auto;">
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-left" id="text-block-id-632f51ad">
<div class="rich-text" style="padding-top:30px; padding-bottom:20px;">
<h3><span style="color: var(--off-black)"><strong>What is your monthly income?</strong></span></h3>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-f1a69892" data-align-siblings="">
<div style="padding-top:5px; padding-bottom:20px;">
<div class="multiple-choice mc-list">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['calculate-your-benefits'].navigation.navigate('next','');" type="radio" id="id-b30bf934" data-tracking="true" data-event-name=""
data-type="multiple-choice" data-label="monthly_income" name="id-f1a69892" data-variable="monthly_income" value="id-b30bf934" data-answer="Less than $1,500" required="" data-destination="next" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Less than $1,500</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['calculate-your-benefits'].navigation.navigate('next','');" type="radio" id="id-5e672cf2" data-tracking="true" data-event-name=""
data-type="multiple-choice" data-label="monthly_income" name="id-f1a69892" data-variable="monthly_income" value="id-5e672cf2" data-answer="$1,500 - $5,000" required="" data-destination="next" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">$1,500 - $5,000</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">3</div><input onclick="window.heyflow['calculate-your-benefits'].navigation.navigate('next','');" type="radio" id="id-49d90d80" data-tracking="true" data-event-name=""
data-type="multiple-choice" data-label="monthly_income" name="id-f1a69892" data-variable="monthly_income" value="id-49d90d80" data-answer="$5,000 - $10,000" required="" data-destination="next" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">$5,000 - $10,000</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">4</div><input onclick="window.heyflow['calculate-your-benefits'].navigation.navigate('next','');" type="radio" id="id-accc5f69" data-tracking="true" data-event-name=""
data-type="multiple-choice" data-label="monthly_income" name="id-f1a69892" data-variable="monthly_income" value="id-accc5f69" data-answer="More than $10,000" required="" data-destination="next" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">More than $10,000</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-abb68367" name="homeowner" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-4fc430e5">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-4bcb576c">
<div class="rich-text" style="padding-top:20px; padding-bottom:25px;">
<h2>Are you a homeowner?</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-236161ec" data-align-siblings="">
<div style="padding-top:5px; padding-bottom:0px;">
<div class="multiple-choice mc-list">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">1</div><input onclick="window.heyflow['calculate-your-benefits'].navigation.navigate('next','');" type="radio" id="id-dc3b4c5e" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="is_homeowner" name="id-236161ec" data-variable="is_homeowner" value="id-dc3b4c5e" data-answer="No" required="" data-destination="next" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="" hey-important="" hey-autoredirect="true"><label>
<div class="option-counter">2</div><input onclick="window.heyflow['calculate-your-benefits'].navigation.navigate('next','');" type="radio" id="id-adfa77f0" data-tracking="true" data-event-name="" data-type="multiple-choice"
data-label="is_homeowner" name="id-236161ec" data-variable="is_homeowner" value="id-adfa77f0" data-answer="Yes" required="" data-destination="next" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="screen-f217f353" name="first-last" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="progress-fc82f6ce">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item"></span> <span class="progress-item"></span> <span
class="progress-item"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-left" id="text-block-headline-9b36dd1d">
<div class="rich-text" style="padding-top:20px; padding-bottom:25px;">
<h3><span style="color: var(--off-black)"><strong>What name will you use on your </strong></span><span style="color: var(--off-black)"><strong><span class="variable-replace" data-variable="program">@program</span></strong></span><span
style="color: var(--off-black)"><strong> application?</strong></span></h3>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="elements-v2">
<div class="block-content elements-container elements-v2-container inner-narrow" data-type="nested-blocks">
<div class="container-style-plain" style="margin-right:0px; margin-bottom:10px; margin-left:0px; padding-right:0px; padding-bottom:5px; padding-left:0px;">
<div class="elements-container-inner inner-narrow mobile-flex-col" style="justify-content:normal;gap:10px; flex-direction:column; align-items:stretch;margin-left:auto;margin-right:auto;">
<div class="block" style="flex-grow:0;" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav with-floating-label floating-label-inline" id="id-2f8233f4-container">
<div style=""><label for="id-2f8233f4">First name</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-2f8233f4" data-type="input" data-label="first_name" data-variable="first_name" data-mask="only-letters" name="id-2f8233f4" placeholder="Max" pattern="^[a-zA-Z0-9]{2,}$"
maxlength="" required="required" autofocus="" autocomplete="off" class="">
<div class="input-floating-label"><span>First name</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
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</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
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</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-2f8233f4">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please enter your first name</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="flex-grow:0;" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav with-floating-label floating-label-inline" id="id-d7c6346c-container">
<div style=""><label for="id-d7c6346c">Last name</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input id="id-d7c6346c" data-type="input" data-label="last_name" data-variable="last_name" data-mask="only-letters" name="id-d7c6346c" placeholder="Muster" pattern="^[a-zA-Z0-9]{2,}$"
maxlength="" required="required" autocomplete="off" class="">
<div class="input-floating-label"><span>Last name</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-d7c6346c">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please enter your last name</span></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-left" id="text-block-id-4db2172a">
<div class="rich-text" style="padding-top:15px; padding-bottom:20px;">
<h3><span style="color: var(--off-black)"><strong>What is your zip code?</strong></span></h3>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="elements-v2">
<div class="block-content elements-container elements-v2-container inner-narrow" data-type="nested-blocks">
<div class="container-style-plain" style="margin-right:0px; margin-bottom:5px; margin-left:0px; padding-right:0px; padding-bottom:5px; padding-left:0px;">
<div class="elements-container-inner inner-narrow mobile-flex-col" style="justify-content:normal;gap:10px; flex-direction:column; align-items:stretch;margin-left:auto;margin-right:auto;">
<div class="block" style="flex-grow:0;" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav with-floating-label floating-label-inline" id="id-82c5a37c-container">
<div style=""><label for="id-82c5a37c">Zip code</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input type="tel" id="id-82c5a37c" data-type="input" data-label="postal_code" data-variable="postal_code" data-mask="only-numbers" name="id-82c5a37c" placeholder="Max" pattern="^\d{5}$"
maxlength="5" required="required" autofocus="" autocomplete="off" class="">
<div class="input-floating-label"><span>Zip code</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-82c5a37c">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please enter a valid zip code</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-left" id="text-block-id-e7bd8fcb">
<div class="rich-text" style="padding-top:0px; padding-right:0px; padding-bottom:5px;">
<h6>Example: 90210</h6>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="generic-button">
<div class="block-content generic-button-block inner-narrow" id="generic-button-block-id-b8a421aa">
<div style="padding-top:10px; padding-bottom:20px;"><button id="id-b8a421aa" class="generic-button continue large"
onclick="window.heyflow['calculate-your-benefits'].buttonClick(this, 'next', '', '{"containerClass":"inner-narrow","icon":null,"nextAction":"next","label":"CONTINUE","type":"generic-button","filename":null,"paddingBottom":20,"name":"button-continue","action":"next","contentClass":"align-center","id":"id-b8a421aa","paddingTop":"10","class":"continue&nbsp;large"}')">
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
<div class="content align-center">
<div class="label-container"><span class="label">CONTINUE</span></div>
</div>
</button></div>
</div>
</div>
</section>
<section id="screen-810ea872" name="birth-year" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="progress-7ffb129a">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item"></span> <span
class="progress-item"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-headline-ac2c3696">
<div class="rich-text" style="padding-top:20px; padding-bottom:25px;">
<h2>Unlock Over $900/Month in Benefits by Meeting Certain Age Requirements</h2>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-left" id="text-block-id-5557d933">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h3><span style="color: var(--off-black)"><strong>What year were you born, <span class="variable-replace" data-variable="first_name">@first_name</span>?</strong></span></h3>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav with-floating-label floating-label-inline" id="id-9daafd89-container">
<div style="padding-top:5px; padding-bottom:10px;"><label for="id-9daafd89">Birth Year</label>
<div class="input">
<div class="input-inner">
<div style="flex:1;position:relative;"><input type="tel" id="id-9daafd89" data-type="input" data-label="birth_year" data-variable="birth_year" data-mask="only-numbers" name="id-9daafd89" placeholder="Example: 1973"
pattern="^(19|20)\d{2}$" maxlength="4" data-trim="" required="required" autofocus="" autocomplete="off" class="">
<div class="input-floating-label"><span>Birth Year</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-9daafd89">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify a valid birth year</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-left" id="text-block-id-51cf121d">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h3><span style="color: var(--off-black)"><strong>What's your job status?</strong></span></h3>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-id-2c32080b" data-align-siblings="">
<div style="padding-top:5px; padding-bottom:20px;">
<div class="multiple-choice mc-list">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="screen-f217f353" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">1</div><input type="radio" id="id-03b5f287" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="employment_status" name="id-2c32080b" data-variable="employment_status"
value="id-03b5f287" data-answer="Unemployed" checked="checked" required="" data-destination="screen-f217f353" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">No Job</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-abb68367" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">2</div><input type="radio" id="id-df225174" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="employment_status" name="id-2c32080b" data-variable="employment_status"
value="id-df225174" data-answer="Part-Time" required="" data-destination="id-abb68367" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Part-Time Job</div>
</div>
</div>
<div></div>
</label></div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option" hey-nextscreen="id-abb68367" hey-important="" hey-autoredirect="false"><label>
<div class="option-counter">3</div><input type="radio" id="id-e479cfe7" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="employment_status" name="id-2c32080b" data-variable="employment_status"
value="id-e479cfe7" data-answer="Full-Time" required="" data-destination="id-abb68367" data-priority="0">
<div class="option-content">
<div class="selector-container radio-selector"><span class="radio"></span></div>
<div class="label-container">
<div class="label">Full-Time Job</div>
</div>
</div>
<div></div>
</label></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="generic-button">
<div class="block-content generic-button-block inner-narrow" id="generic-button-block-id-f60c381c">
<div style="padding-top:10px; padding-bottom:20px;"><button id="id-f60c381c" class="generic-button continue large"
onclick="window.heyflow['calculate-your-benefits'].buttonClick(this, 'next', 'screen-96b0c86b', '{"containerClass":"inner-narrow","destination":"screen-96b0c86b","icon":null,"nextAction":"next","label":"CONTINUE","type":"generic-button","filename":null,"paddingBottom":20,"name":"button-continue","action":"next","contentClass":"align-center","id":"id-f60c381c","paddingTop":"10","class":"continue&nbsp;large"}')">
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
<div class="content align-center">
<div class="label-container"><span class="label">CONTINUE</span></div>
</div>
</button></div>
</div>
</div>
</section>
<section id="id-d2e4efee" name="email-phone" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="progress-0e4f9d5f">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item filled"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-left" id="text-block-id-4add57cc">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h3><span style="color: var(--off-black)"><strong>Where would you like your results sent, </strong></span><span style="color: var(--off-black)"><strong><span class="variable-replace"
data-variable="first_name">@first_name</span></strong></span><span style="color: var(--off-black)"><strong>?</strong></span></h3>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav with-floating-label floating-label-inline" id="id-c561f3f2-container">
<div style="padding-top:5px; padding-bottom:5px;"><label for="id-c561f3f2">Email address</label>
<div class="input has-prefix">
<div class="input-inner">
<div class="input-decorator input-prefix input-prefix-icon"><i class="material-icons" icon="mail_outline">mail_outline</i></div>
<div style="flex:1;position:relative;"><input type="url" id="id-c561f3f2" data-type="input" data-label="email" data-variable="email" data-mask="" name="id-c561f3f2" placeholder="address@mail.com" pattern="^\S+@\S+\.\S+$" maxlength=""
required="required" autocomplete="email" class="">
<div class="input-floating-label"><span>Email address</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-c561f3f2">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please enter a valid email address</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav with-floating-label floating-label-inline" id="id-7e67709a-container">
<div style="padding-top:5px; padding-bottom:10px;"><label for="id-7e67709a">Phone number</label>
<div class="input has-prefix">
<div class="input-inner">
<div class="input-decorator input-prefix input-prefix-icon"><i class="material-icons" icon="phone">phone</i></div>
<div style="flex:1;position:relative;"><input type="tel" id="id-7e67709a" data-type="input" data-label="phone" data-variable="phone" data-mask="only-numbers" name="id-7e67709a" placeholder="" pattern="^\d{10}$" maxlength="10"
data-trim="" required="required" autocomplete="tel" class="">
<div class="input-floating-label"><span>Phone number</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div><datalist id="datalist-id-7e67709a">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please enter a valid phone number</span></div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-left" id="text-block-rich-text-0e91f44a">
<div class="rich-text" style="padding-top:0px; padding-right:0px; padding-bottom:0px;">
<h6>Example: 1112223333</h6>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="generic-button">
<div class="block-content generic-button-block inner-narrow" id="generic-button-block-button-ef32ff86">
<div style="padding-top:10px; padding-bottom:5px;"><button id="button-ef32ff86" class="generic-button submit large"
onclick="window.heyflow['calculate-your-benefits'].buttonClick(this, 'submit', '', '{"containerClass":"inner-narrow","label":"FINISH!","nextAction":"next","type":"generic-button","tracking":true,"paddingBottom":"5","name":"button-submit","action":"submit","contentClass":"align-space-between","eventName":"generate_lead","id":"button-ef32ff86","paddingTop":"10","class":"submit&nbsp;large"}')">
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
<div class="content align-space-between">
<div class="label-container"><span class="label">FINISH!</span></div><span class="graphic"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<path d="M219.53563,121.02,50.62075,26.42762A8,8,0,0,0,39.178,36.09836l31.86106,89.211a8,8,0,0,1,0,5.38138L39.178,219.90164a8,8,0,0,0,11.44277,9.67074l168.91488-94.59233A8,8,0,0,0,219.53563,121.02Z" fill="none" stroke="currentColor"
stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></path>
<line x1="72" y1="128" x2="136" y2="128" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg></span>
</div>
</button></div>
</div>
</div>
<div class="block" style="" data-blocktype="elements-v2">
<div class="block-content elements-container elements-v2-container inner-full" data-type="nested-blocks">
<div class="container-style-plain" style="margin-top:0px; margin-right:10px; margin-bottom:10px; margin-left:10px; padding-top:10px; padding-bottom:10px;">
<div class="elements-container-inner inner-narrow" style="justify-content:normal;align-items:center;flex-direction:row;margin-left:auto;margin-right:auto;">
<div class="block" style="" data-blocktype="html">
<h5><label for="leadid_tcpa_disclosure" id="nxv_form_disclaimer_benefitsapplication">
<div>By clicking “Submit”, you agree to the Fun Ventures, LLC <a href="https://www.benefitsapplication.com/text-terms">Texting Terms</a>. Fun Ventures, LLC and up to 5 participating partners may contact you on the number you
provided for marketing purposes, discuss available services, etc. Recurring message frequency varies. Messages and Phone Calls may be sent using pre-recorded messages, auto-dialer or other automated technology. You are not
required to provide consent as a condition of service. Partners have the option, but are not required, to send text messages to you. Frequency from partners may vary. Reply "STOP" to unsubscribe. Reply "HELP" for help. Message and
data rates may apply. Your number will be held in accordance with our <a href="https://www.benefitsapplication.com/privacy">Privacy Policy</a> & <a href="https://www.benefitsapplication.com/terms">Terms of Use</a>.</div>
</label></h5>
</div>
</div>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="simple-checkbox-v2">
<div class="block-content simple-checkbox simple-checkbox-block inner-narrow" id="simple-checkbox-block-id-03c3690c">
<div style="padding-right:0px; padding-bottom:10px; padding-left:0px;"><label for="id-03c3690c"><input type="checkbox" hey-type="simple-checkbox" data-type="simple-checkbox" id="id-03c3690c" name="id-03c3690c" data-label="coreg_optin_usag"
data-answer="true" value="true">
<div class="simple-checkbox-content" style="display:flex;"><span class="checkbox"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></span>
<div class="label-container"><span class="simple-checkbox-text rich-text">
<p>Financial assistance is available in your area. Would you like to learn if you qualify today?</p>
</span></div>
</div>
</label></div>
</div>
</div>
</section>
<section id="screen-96b0c86b" name="nx-redirect" data-type="user" class="undefined with-avatar" data-header="header">
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-570bdcc4">
<div class="rich-text" style="padding-top:40px; padding-bottom:0px;">
<p>Calculating eligibility for benefit programs...</p>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="elements-v2">
<div class="block-content elements-container elements-v2-container inner-full" data-type="nested-blocks">
<div class="container-style-plain" style="margin-top:0px; margin-right:10px; margin-bottom:10px; margin-left:10px; padding-top:0px; padding-bottom:10px;">
<div class="elements-container-inner inner-narrow" style="justify-content:normal;align-items:center;flex-direction:row;margin-left:auto;margin-right:auto;">
<div class="block" style="" data-blocktype="loader">
<div style="" class="block-content loader-block center inner-narrow" id="loader-block-loader-aee0cd93" data-id="loader-aee0cd93" data-timeout="3000" data-action="redirect"
data-options="{"redirectURL":"https://tracker.cx/?flux_action=1&amp;flux_f=1806277004004298190&amp;flux_ffn=1806277470198007926&amp;nx_clid=@nx_clid","type":"loader","timeout":"3000","target":"_self","hide":false,"paddingBottom":20,"name":"loader","action":"redirect","disabled":false,"id":"loader-aee0cd93","paddingTop":20,"class":"center&nbsp;inner-narrow"}">
<div style="padding-top:20px; padding-bottom:20px;">
<div id="loader-aee0cd93" class="circle-loader">
<div class="circle-loader-checkmark draw"></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-4d46f2c6" name="coreg-backup" data-type="user" class="undefined with-avatar" data-header="header" data-footer="footer">
<div class="block" style="" data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-rect" id="id-9cea959d">
<div style="padding-top:20px; padding-bottom:20px;"><span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span class="progress-item filled"></span> <span
class="progress-item filled"></span> <span class="progress-item"></span></div>
</div>
</div>
<div class="block" style="" data-blocktype="rich-text">
<div class="block-content text-block inner-narrow align-left" id="text-block-id-70ddffde">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px;">
<h3><span style="color: var(--off-black)"><strong>Where would you like your results sent, </strong></span><span style="color: var(--off-black)"><strong><span class="variable-replace"
data-variable="first_name">@first_name</span></strong></span><span style="color: var(--off-black)"><strong>?</strong></span></h3>
</div>
</div>
</div>
<div class="block" style="" data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav with-floating-label floating-label-inline" id="id-d2e4c9ec-container">
<div style="padding-top:5px; padding-bottom:5px;"><label for="id-d2e4c9ec">Email address</label>
<div class="input has-prefix">
<div class="input-inner">
<div class="input-decorator input-prefix input-prefix-icon"><i class="material-icons" icon="mail_outline">mail_outline</i></div>
<div style="flex:1;position:relative;"><input type="url" id="id-d2e4c9ec" data-type="input" data-label="email1" data-variable="email1" data-mask="" name="id-d2e4c9ec" placeholder="address@mail.com" pattern="^\S+@\S+\.\S+$" maxlength=""
required="required" autocomplete="email" class="">
<div class="input-floating-label"><span>Email address</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
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<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
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<div class="block-content simple-checkbox simple-checkbox-block inner-narrow" id="simple-checkbox-block-id-f5bfc762">
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<p><strong>FOUND MONEY GUIDE:</strong> You may be entitled to $1,000 or more! Billions of dollars in unclaimed money from the government is available to people in the USA. Find out if you are eligible.
<a target="_blank" href="https://foundmoneyguide.com/privacy-notice/">Privacy Policy</a></p>
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THIS SITE IS PRIVATELY OWNED AND IS NOT AFFILIATED WITH ANY GOVERNMENT AGENCY. FINAL ELIGIBILITY QUESTIONS FOR LIHEAP - LET'S GO! CHECKING REQUIREMENTS IN 04281 src src Option 1Option 2 Please specify an answer utm_source utm_source Option 1Option 2 Please specify an answer laminLid laminLid Option 1Option 2 Please specify an answer program program Option 1Option 2 Please specify an answer nx_clid nx_clid Option 1Option 2 Please specify an answer msclkid msclkid Option 1Option 2 Please specify an answer disclaimer_variable disclaimer_variable Option 1Option 2 Please specify an answer brand brand Option 1Option 2 Please specify an answer leadid_token leadid_token Option 1Option 2 Please specify an answer s_src s_src Option 1Option 2 Please specify an answer s_cid s_cid Option 1Option 2 Please specify an answer s_agid s_agid Option 1Option 2 Please specify an answer s_tid s_tid Option 1Option 2 Please specify an answer s_mt s_mt Option 1Option 2 Please specify an answer s_n s_n Option 1Option 2 Please specify an answer s_d s_d Option 1Option 2 Please specify an answer s_adid s_adid Option 1Option 2 Please specify an answer s_aid s_aid Option 1Option 2 Please specify an answer s_pos s_pos Option 1Option 2 Please specify an answer s_plc s_plc Option 1Option 2 Please specify an answer s_k s_k Option 1Option 2 Please specify an answer DO YOU CURRENTLY RECEIVE ANY GOVERNMENT BENEFITS? If yes, please select all that apply: 1 Supplemental Security Income (SSI) 2 Section 8 Housing 3 SNAP (Food Stamps) 4 Medicare 5 1 None CONTINUE FACT: THE USA SPENDS AROUND TWO TRILLION DOLLARS EACH YEAR ON PROGRAMS LIKE LIHEAP TO HELP PEOPLE LIKE YOU AND ME! DO YOU CURRENTLY RECEIVE SOCIAL SECURITY DISABILITY BENEFITS? 1 No 2 Yes DO YOU EXPECT TO BE OUT OF WORK FOR AT LEAST A YEAR DUE TO YOUR HEALTH? We can help you apply, appeal, or maximize your disability benefits. 1 Yes 2 No FACT: IF YOU ARE APPROVED FOR SSDI BENEFITS IN 2023, YOU COULD RECEIVE UP TO $3,148/MONTH TO HELP COVER YOUR LIVING EXPENSES AND PROVIDE FINANCIAL STABILITY. BACK HAVE YOU HAD A FULL-TIME JOB WITHIN THE PAST 5 YEARS? 1 Yes 2 No ARE YOU ACTIVELY WORKING WITH A DISABILITY ADVOCATE OR ATTORNEY? 1 No 2 Yes WHAT DESCRIBES YOUR SITUATION? Select any that apply: 1 Cancer 2 Multiple Medical Issues 3 Struggle Walking 4 Knee Pain 5 Back Pain 6 Need Help Applying 7 Hearing Issues 8 Heart Disease 9 Arthritis 10 Vision / Blindness 11 In An Accident 12 Mental Health 13 PTSD 14 Depression 15 Physical Limitations 16 SSD Appeal 17 Drug Addiction 18 Learning Disability 19 Debt Help 20 Call me to Discuss ARE YOU SEEING A DOCTOR OR TAKING PRESCRIPTION MEDICATION TO HELP WITH YOUR SITUATION? 1 Yes 2 No HAVE YOU OR YOUR SPOUSE SERVED IN THE US MILITARY? 🇺🇸 1 Yes 2 No DO YOU EARN LESS THAN $1,000 A MONTH? 1 Yes 2 No CONTINUE BACK HAVE YOU OR A LOVED ONE BEEN INJURED BY ONE OF THE FOLLOWING, WITHIN 2 YEARS? Select any that apply: 1 Auto Accident 2 Work Injury 3 Medical Malpractice 4 Slip & Fall 5 Other Injury 6 Does Not Apply HAVE YOU OR A LOVED ONE BEEN EXPOSED TO ANY OF THE FOLLOWING: Select any that apply: 1 Hernia Mesh Implant 2 Talcum (Baby Powder) Use 3 Roundup Weed Killer 4 3M Combat Ear Plugs 5 Firefighter Foam Exposure 6 Toxic Premature Baby Formula 7 Camp Lejeune Water Contamination 8 Paraquat Weed Killer 9 Hair Relaxer 10 Does Not Apply CONTINUE WHAT IS YOUR CURRENT HOUSEHOLD CREDIT CARD DEBT AMOUNT? We can show you options to eliminate or consolidate your debt. 1 More than $50,000 2 Around $20,000 3 Around $15,000 4 Around $10,000 5 Around $5,000 DESCRIBE YOUR DEBT SITUATION: Select any that apply: 1 Behind on payments 2 Can't Make Future Payments 3 Need Help Reducing Payments 4 Bankruptcy Help 5 Tax debt 6 Fixed Income. Need Debt Reduction. 7 Call Me to Discuss ESTIMATE THE VALUE OF YOUR ASSETS (Home + Car + Cash + Investments) 1 Less than $50,000 2 More than $50,000 CONTINUE WHAT IS YOUR MONTHLY INCOME? 1 Less than $1,500 2 $1,500 - $5,000 3 $5,000 - $10,000 4 More than $10,000 ARE YOU A HOMEOWNER? 1 No 2 Yes WHAT NAME WILL YOU USE ON YOUR @PROGRAM APPLICATION? First name First name Option 1Option 2 Please enter your first name Last name Last name Option 1Option 2 Please enter your last name WHAT IS YOUR ZIP CODE? Zip code Zip code Option 1Option 2 Please enter a valid zip code EXAMPLE: 90210 CONTINUE UNLOCK OVER $900/MONTH IN BENEFITS BY MEETING CERTAIN AGE REQUIREMENTS WHAT YEAR WERE YOU BORN, @FIRST_NAME? Birth Year Birth Year Option 1Option 2 Please specify a valid birth year WHAT'S YOUR JOB STATUS? 1 No Job 2 Part-Time Job 3 Full-Time Job CONTINUE WHERE WOULD YOU LIKE YOUR RESULTS SENT, @FIRST_NAME? Email address mail_outline Email address Option 1Option 2 Please enter a valid email address Phone number phone Phone number Option 1Option 2 Please enter a valid phone number EXAMPLE: 1112223333 FINISH! BY CLICKING “SUBMIT”, YOU AGREE TO THE FUN VENTURES, LLC TEXTING TERMS. FUN VENTURES, LLC AND UP TO 5 PARTICIPATING PARTNERS MAY CONTACT YOU ON THE NUMBER YOU PROVIDED FOR MARKETING PURPOSES, DISCUSS AVAILABLE SERVICES, ETC. RECURRING MESSAGE FREQUENCY VARIES. MESSAGES AND PHONE CALLS MAY BE SENT USING PRE-RECORDED MESSAGES, AUTO-DIALER OR OTHER AUTOMATED TECHNOLOGY. YOU ARE NOT REQUIRED TO PROVIDE CONSENT AS A CONDITION OF SERVICE. PARTNERS HAVE THE OPTION, BUT ARE NOT REQUIRED, TO SEND TEXT MESSAGES TO YOU. FREQUENCY FROM PARTNERS MAY VARY. REPLY "STOP" TO UNSUBSCRIBE. REPLY "HELP" FOR HELP. MESSAGE AND DATA RATES MAY APPLY. YOUR NUMBER WILL BE HELD IN ACCORDANCE WITH OUR PRIVACY POLICY & TERMS OF USE. Financial assistance is available in your area. Would you like to learn if you qualify today? Calculating eligibility for benefit programs... WHERE WOULD YOU LIKE YOUR RESULTS SENT, @FIRST_NAME? Email address mail_outline Email address Option 1Option 2 Please enter a valid email address Phone number phone Phone number Option 1Option 2 Please enter a valid phone number EXAMPLE: 1112223333 FINISH! FOUND MONEY GUIDE: You may be entitled to $1,000 or more! Billions of dollars in unclaimed money from the government is available to people in the USA. Find out if you are eligible. Privacy Policy ERROR SORRY, YOUR RESPONSE COULD NOT BE SENT. PLEASE CHECK YOUR INTERNET CONNECTION. AN ERROR OCCURRED. Activate JavaScript if you have it deactivated in your browser.