{"id":1439,"date":"2023-11-02T22:15:28","date_gmt":"2023-11-02T22:15:28","guid":{"rendered":"https:\/\/givingtothenations.kingfisherweb.dev\/?page_id=1439"},"modified":"2025-01-20T17:57:44","modified_gmt":"2025-01-20T23:57:44","slug":"g2n-healthy-essentials-pantry-apply","status":"publish","type":"page","link":"https:\/\/givingtothenations.org\/g2n-healthy-essentials-pantry-apply\/","title":{"rendered":"Healthy Essentials Pantry"},"content":{"rendered":"<p><strong style=\"color: red;\">We serve residents throughout Southeastern Wisconsin. Our primary focus area is Racine County east of I-94.<\/strong><\/p>\n<h2>Healthy Essentials Pantry Application Process<\/h2>\n<p>In order to help you, we need your help. Please complete the\u00a0<u>INTAKE FORM<\/u> and the <u>PRODUCT LIST<\/u>. The Product List will become available after the Intake Form is submitted.<\/p>\n<p>Both forms can be completed online or download and returned to us (instructions are on the forms).<\/p>\n<hr \/>\n<p><strong>Download Forms<\/strong><\/p>\n<ul>\n<li><a href=index-57.html target=\"_blank\" rel=\"noopener\">Intake Form (English Only)<\/a><\/li>\n<li><a href=index-58.html target=\"_blank\" rel=\"noopener\">Product List (English Only)<\/a><\/li>\n<li><a href=index-59.html target=\"_blank\" rel=\"noopener\">Intake Form (English and Spanish)<\/a><\/li>\n<li><a href=index-60.html target=\"_blank\" rel=\"noopener\">Product List (English and Spanish)<\/a><\/li>\n<\/ul>\n<hr \/>\n<h3>Intake Form (English Only)<\/h3>\n<div class='fluentform ff-default fluentform_wrapper_5 ffs_default_wrap'><form data-form_id=\"5\" id=\"fluentform_5\" class=\"frm-fluent-form fluent_form_5 ff-el-form-top ff_form_instance_5_1 ff-form-loading ff-form-has-steps ffs_default\" data-form_instance=\"ff_form_instance_5_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Client Intake Form<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='1439' \/><input type=\"hidden\" id=\"_fluentform_5_fluentformnonce\" name=\"_fluentform_5_fluentformnonce\" value=\"d79afa7ce0\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/1439\" \/><div class='ff-step-container' data-name=\"step_start-5_21\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"no\" data-enable_step_page_resume=\"no\" data-animation_type=\"slide\" ><div class='ff-step-header'><div class='ff-el-progress-status'><\/div>\n            <div class='ff-el-progress'>\n                <div class='ff-el-progress-bar'><span><\/span><\/div>\n            <\/div>\n            <ul style='display: none' class='ff-el-progress-title'>\n                <li><\/li><li><\/li><li><\/li><li><\/li>\n            <\/ul><\/div><span class='ff_step_start'><\/span><div class='ff-step-body'><div class=\"fluentform-step active\" data-name=\"step_start-5_21\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"no\" data-enable_step_page_resume=\"no\" data-animation_type=\"slide\" ><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-5_1\" ><h2 style=\"text-align: center\"><span style=\"color: #000000\"><strong><em>Need help? Please fill out the form completely so we may serve you better.<\/em><\/strong><\/span><\/h2><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_2\" ><h3 class='ff-el-section-title'>CLIENT DOCUMENTATION<\/h3><div class='ff-section_break_desk'><h5>\u00a0<\/h5><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Are you completing this form at a GIVEAWAY EVENT?\">Are you completing this form at a GIVEAWAY EVENT?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=at_giveaway_758510b1eda25073652ab50567c5db13><input  type=\"radio\" name=\"at_giveaway\" data-name=\"at_giveaway\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='at_giveaway_758510b1eda25073652ab50567c5db13' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=at_giveaway_c435814305515e472deca246a4c14ce0><input  type=\"radio\" name=\"at_giveaway\" data-name=\"at_giveaway\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='at_giveaway_c435814305515e472deca246a4c14ce0' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_3\" ><h3 class='ff-el-section-title'>How did you hear about Giving to the Nations?<\/h3><div class='ff-section_break_desk'><p><b>\u00a0Please answer the 5 questions below.<\/b><\/p><\/div><hr \/><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_4  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 25%;'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_howlearned' aria-label=\"How did you learn about our program?Ne\">How did you learn about our program?Ne<\/label><\/div><div class='ff-el-input--content'><select name=\"howlearned\" id=\"ff_5_howlearned\" class=\"ff-el-form-control\" data-name=\"howlearned\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">- Select -<\/option><option value=\"Business\"  >Business<\/option><option value=\"Church\"  >Church<\/option><option value=\"Co-Worker\"  >Co-Worker<\/option><option value=\"Community Center\"  >Community Center<\/option><option value=\"Community Service\"  >Community Service<\/option><option value=\"Facebook\"  >Facebook<\/option><option value=\"Family\"  >Family<\/option><option value=\"Flyer\"  >Flyer<\/option><option value=\"Food Pantry\"  >Food Pantry<\/option><option value=\"Friend\"  >Friend<\/option><option value=\"Giveaway\"  >Giveaway<\/option><option value=\"Neighbor\"  >Neighbor<\/option><option value=\"Newspaper\"  >Newspaper<\/option><option value=\"Not listed here\"  >Not listed here<\/option><option value=\"Online\"  >Online<\/option><option value=\"Organization\"  >Organization<\/option><option value=\"Other Person\"  >Other Person<\/option><option value=\"Residence\/Home\"  >Residence\/Home<\/option><option value=\"School\"  >School<\/option><option value=\"Sign\"  >Sign<\/option><option value=\"Unknown\"  >Unknown<\/option><option value=\"Used program before\"  >Used program before<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_personorg' aria-label=\"More information about the person or organization that referred you.\">More information about the person or organization that referred you.<\/label><\/div><div class='ff-el-input--content'><select name=\"personorg\" id=\"ff_5_personorg\" class=\"ff-el-form-control\" data-name=\"personorg\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">- Select -<\/option><option value=\"Arise Store\"  >Arise Store<\/option><option value=\"Badgercare\/Forward Health\"  >Badgercare\/Forward Health<\/option><option value=\"Bethany Apartments\"  >Bethany Apartments<\/option><option value=\"Birth To Three Programs\"  >Birth To Three Programs<\/option><option value=\"Boost Program\"  >Boost Program<\/option><option value=\"Brother\"  >Brother<\/option><option value=\"CCS-Comprehensive Community Services\"  >CCS-Comprehensive Community Services<\/option><option value=\"CDPU-Central Document Processing Unit\"  >CDPU-Central Document Processing Unit<\/option><option value=\"CPS-Child Protective Services\"  >CPS-Child Protective Services<\/option><option value=\"CRCHD-Central Racine County Health Dept\"  >CRCHD-Central Racine County Health Dept<\/option><option value=\"Cesar Chavez Community Center\"  >Cesar Chavez Community Center<\/option><option value=\"Here To Help Program\"  >Here To Help Program<\/option><option value=\"Church\"  >Church<\/option><option value=\"Church Member\"  >Church Member<\/option><option value=\"City of Racine Housing Dept\"  >City of Racine Housing Dept<\/option><option value=\"Crossroads\"  >Crossroads<\/option><option value=\"Daughter\"  >Daughter<\/option><option value=\"DDSI-Developmental Disabilities Information Services\"  >DDSI-Developmental Disabilities Information Services<\/option><option value=\"Deals For Days\"  >Deals For Days<\/option><option value=\"DoorDash\"  >DoorDash<\/option><option value=\"Dr John Bryant Community Center\"  >Dr John Bryant Community Center<\/option><option value=\"Dr Martin Luther King Jr Community Center\"  >Dr Martin Luther King Jr Community Center<\/option><option value=\"Existing program user\"  >Existing program user<\/option><option value=\"Facebook-General Post\"  >Facebook-General Post<\/option><option value=\"Facebook-Giving to the Nations\"  >Facebook-Giving to the Nations<\/option><option value=\"Facebook-Racine Town Hall\"  >Facebook-Racine Town Hall<\/option><option value=\"Family Service of Racine\"  >Family Service of Racine<\/option><option value=\"FAST-Families and Schools Together\"  >FAST-Families and Schools Together<\/option><option value=\"Father\"  >Father<\/option><option value=\"Focus on Fathers\"  >Focus on Fathers<\/option><option value=\"Food Pantry\"  >Food Pantry<\/option><option value=\"FoodShare\"  >FoodShare<\/option><option value=\"Foster Care\"  >Foster Care<\/option><option value=\"Friend\"  >Friend<\/option><option value=\"Gateway Technical College\"  >Gateway Technical College<\/option><option value=\"Giveaway Event-Cleaning Products\"  >Giveaway Event-Cleaning Products<\/option><option value=\"Giveaway Event-Other\"  >Giveaway Event-Other<\/option><option value=\"Giving to the Nations-Website\"  >Giving to the Nations-Website<\/option><option value=\"HAFA-Hmong American Friendship Association\"  >HAFA-Hmong American Friendship Association<\/option><option value=\"HALO\"  >HALO<\/option><option value=\"Home Visit\"  >Home Visit<\/option><option value=\"Hope Community Church\"  >Hope Community Church<\/option><option value=\"Hopes Center\"  >Hopes Center<\/option><option value=\"Hospitality Center\"  >Hospitality Center<\/option><option value=\"I don't know\"  >I don't know<\/option><option value=\"Independent Living Coordinator\"  >Independent Living Coordinator<\/option><option value=\"Jerstad-Algerholm School\"  >Jerstad-Algerholm School<\/option><option value=\"Journal Times\"  >Journal Times<\/option><option value=\"Kingdom Builders\"  >Kingdom Builders<\/option><option value=\"Knapp Elementary School\"  >Knapp Elementary School<\/option><option value=\"Landlord\"  >Landlord<\/option><option value=\"McMynn Towers\"  >McMynn Towers<\/option><option value=\"Medicaid\"  >Medicaid<\/option><option value=\"Medicare\"  >Medicare<\/option><option value=\"Milwaukee Consortium for Hmong Health\"  >Milwaukee Consortium for Hmong Health<\/option><option value=\"Mother\"  >Mother<\/option><option value=\"Not listed here\"  >Not listed here<\/option><option value=\"Oxford House\"  >Oxford House<\/option><option value=\"Racine City Safety Support\"  >Racine City Safety Support<\/option><option value=\"Racine County Jail\"  >Racine County Jail<\/option><option value=\"Racine Diaper Ministry\"  >Racine Diaper Ministry<\/option><option value=\"Racine Kenosha Change Report Center\"  >Racine Kenosha Change Report Center<\/option><option value=\"Racine Vocational Ministry\"  >Racine Vocational Ministry<\/option><option value=\"RCHSD-Racine County Human Services Dept\"  >RCHSD-Racine County Human Services Dept<\/option><option value=\"Relative\"  >Relative<\/option><option value=\"Rental Assistance\"  >Rental Assistance<\/option><option value=\"ResCare\"  >ResCare<\/option><option value=\"Roosevelt Elementary School\"  >Roosevelt Elementary School<\/option><option value=\"RUSD-Racine Unified School District\"  >RUSD-Racine Unified School District<\/option><option value=\"Safe Haven of Racine\"  >Safe Haven of Racine<\/option><option value=\"Sister\"  >Sister<\/option><option value=\"Social Worker\"  >Social Worker<\/option><option value=\"Society's Assets\"  >Society's Assets<\/option><option value=\"Son\"  >Son<\/option><option value=\"SOHWIAM-Stand on His Word International Ministries\"  >SOHWIAM-Stand on His Word International Ministries<\/option><option value=\"Spanish Center of Racine\"  >Spanish Center of Racine<\/option><option value=\"St Vincent de Paul\"  >St Vincent de Paul<\/option><option value=\"Starts Now Program\"  >Starts Now Program<\/option><option value=\"Trinity School\"  >Trinity School<\/option><option value=\"UMOS\"  >UMOS<\/option><option value=\"Veterans Outreach Program\"  >Veterans Outreach Program<\/option><option value=\"W2 Job Club\"  >W2 Job Club<\/option><option value=\"Welfare\"  >Welfare<\/option><option value=\"WERA-Wisconsin Emergency Rental Assistance Program\"  >WERA-Wisconsin Emergency Rental Assistance Program<\/option><option value=\"WKRP-Wisconsin Kenosha Racine Partnership\"  >WKRP-Wisconsin Kenosha Racine Partnership<\/option><option value=\"Woman's Resource Center\"  >Woman's Resource Center<\/option><option value=\"Workforce Development Center\"  >Workforce Development Center<\/option><option value=\"WOW Program at Ascension\"  >WOW Program at Ascension<\/option><option value=\"YWCA\"  >YWCA<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_titleposition' aria-label=\"What is the title or position of the person who referred you?\">What is the title or position of the person who referred you?<\/label><\/div><div class='ff-el-input--content'><select name=\"titleposition\" id=\"ff_5_titleposition\" class=\"ff-el-form-control\" data-name=\"titleposition\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">- Select -<\/option><option value=\"Case Manager\"  >Case Manager<\/option><option value=\"Case Worker\"  >Case Worker<\/option><option value=\"Home Visit\"  >Home Visit<\/option><option value=\"I don't know\"  >I don't know<\/option><option value=\"Inmate\"  >Inmate<\/option><option value=\"Landlord\"  >Landlord<\/option><option value=\"Mental Health Therapist\"  >Mental Health Therapist<\/option><option value=\"Not listed here\"  >Not listed here<\/option><option value=\"Nurse\"  >Nurse<\/option><option value=\"Social Worker\"  >Social Worker<\/option><option value=\"Teacher\"  >Teacher<\/option><option value=\"Therapist Team\"  >Therapist Team<\/option><option value=\"Visiting Nurse\"  >Visiting Nurse<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-4' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_personname' >What is the person's name who referred you?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"personname\" class=\"ff-el-form-control\" data-name=\"personname\" id=\"ff_5_personname\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_otherinfo' aria-label=\"Please tell us anything else you would like us to know about how you heard about Giving to the Nations or our program.\">Please tell us anything else you would like us to know about how you heard about Giving to the Nations or our program.<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"otherinfo\" class=\"ff-el-form-control\" data-name=\"otherinfo\" id=\"ff_5_otherinfo\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Have you used our services before?\">Have you used our services before?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=usedservices_1_5f070c6ae3adf0ec23c69e8418b1bc27><input  type=\"radio\" name=\"usedservices_1\" data-name=\"usedservices_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='usedservices_1_5f070c6ae3adf0ec23c69e8418b1bc27' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=usedservices_1_47eb93af844098859ce4620cffe64df9><input  type=\"radio\" name=\"usedservices_1\" data-name=\"usedservices_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='usedservices_1_47eb93af844098859ce4620cffe64df9' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Are you currently homeless?\">Are you currently homeless?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=homeless_8bb4da32cef7a2902f8894974cd5bf1b><input  type=\"radio\" name=\"homeless\" data-name=\"homeless\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='homeless_8bb4da32cef7a2902f8894974cd5bf1b' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=homeless_fb0de8db3f770812ca0005eb711a5d32><input  type=\"radio\" name=\"homeless\" data-name=\"homeless\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='homeless_fb0de8db3f770812ca0005eb711a5d32' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_4\" ><h3 class='ff-el-section-title'>CLIENT INFORMATION<\/h3><div class='ff-section_break_desk'><h5>\u00a0<\/h5><\/div><hr \/><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_1 .form_box '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_names_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_5_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"First Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_names_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_5_names_last_name_\" class=\"ff-el-form-control\" placeholder=\"Last Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_5\" ><h3 class='ff-el-section-title'>Mailing Address &amp; Phone Number<\/h3><div class='ff-section_break_desk'><p><strong>Please make sure your mailing address and phone number are entered correctly.<\/strong> We <span style=\"text-decoration: underline\">may be able to help<\/span> by having your personal care, baby care or home cleaning products delivered to you by DoorDash.<\/p><\/div><hr \/><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_1\" ><div class='ff-el-input--label'><label aria-label=Address>Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_address_1_address_line_1_' aria-label=\"Address 1\">Address 1<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_1]\" id=\"ff_5_address_1_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"Street Address\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_1_address_line_2_' aria-label=\"Address 2\">Address 2<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_2]\" id=\"ff_5_address_1_address_line_2_\" class=\"ff-el-form-control\" placeholder=\"Apartment #, Upper, Lower, or Lot #\" data-key_name=\"address_line_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_address_1_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[city]\" id=\"ff_5_address_1_city_\" class=\"ff-el-form-control\" placeholder=\"City\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_address_1_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[state]\" id=\"ff_5_address_1_state_\" class=\"ff-el-form-control\" placeholder=\"State\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_address_1_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[zip]\" id=\"ff_5_address_1_zip_\" class=\"ff-el-form-control\" placeholder=\"Zip\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_county' aria-label=\"County\">County<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"county\" class=\"ff-el-form-control\" placeholder=\"Example: Racine, Milwaukee, Kenosha\" data-name=\"county\" id=\"ff_5_county\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Address type?\">Address type?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=addresstype_f0a78fe7605f7c30420ab13b68443f80><input  type=\"radio\" name=\"addresstype\" data-name=\"addresstype\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Mailing address only\"  id='addresstype_f0a78fe7605f7c30420ab13b68443f80' aria-label='Mailing address only' aria-invalid='false' aria-required=true> <span>Mailing address only<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=addresstype_77d4a9a1ce67c6354b8f5b70eb6a38fe><input  type=\"radio\" name=\"addresstype\" data-name=\"addresstype\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"I live at this address\"  id='addresstype_77d4a9a1ce67c6354b8f5b70eb6a38fe' aria-label='I live at this address' aria-invalid='false' aria-required=true> <span>I live at this address<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_telephone' aria-label=\"Phone\">Phone<\/label><\/div><div class='ff-el-input--content'><input name=\"telephone\" class=\"ff-el-form-control ff-el-phone ff_el_with_extended_validation\" type=\"tel\" placeholder=\"Number\" data-name=\"telephone\" id=\"ff_5_telephone\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Type\">Type<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=phonetype_84dd1c65276bc7c8590460683db69226><input  type=\"radio\" name=\"phonetype\" data-name=\"phonetype\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Mobile\"  id='phonetype_84dd1c65276bc7c8590460683db69226' aria-label='Mobile' aria-invalid='false' aria-required=true> <span>Mobile<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=phonetype_4b7f68723897bae1e9320d2899538f54><input  type=\"radio\" name=\"phonetype\" data-name=\"phonetype\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Other\"  id='phonetype_4b7f68723897bae1e9320d2899538f54' aria-label='Other' aria-invalid='false' aria-required=true> <span>Other<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_emailaddress' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"emailaddress\" id=\"ff_5_emailaddress\" class=\"ff-el-form-control\" placeholder=\"Email Address\" data-name=\"emailaddress\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Best contact method (What is the best way to get ahold of you?)\">Best contact method (What is the best way to get ahold of you?)<\/label><div class=\"ff-el-tooltip\" data-content=\"If you choose &quot;Phone Call&quot; please write down our phone number, 920-770-8884, so you will know it is us when we call you.\"><svg width=\"16\" height=\"16\" viewBox=\"0 0 25 25\"><path d=\"m329 393l0-46c0-2-1-4-2-6-2-2-4-3-7-3l-27 0 0-146c0-3-1-5-3-7-2-1-4-2-7-2l-91 0c-3 0-5 1-7 2-1 2-2 4-2 7l0 46c0 2 1 5 2 6 2 2 4 3 7 3l27 0 0 91-27 0c-3 0-5 1-7 3-1 2-2 4-2 6l0 46c0 3 1 5 2 7 2 1 4 2 7 2l128 0c3 0 5-1 7-2 1-2 2-4 2-7z m-36-256l0-46c0-2-1-4-3-6-2-2-4-3-7-3l-54 0c-3 0-5 1-7 3-2 2-3 4-3 6l0 46c0 3 1 5 3 7 2 1 4 2 7 2l54 0c3 0 5-1 7-2 2-2 3-4 3-7z m182 119c0 40-9 77-29 110-20 34-46 60-80 80-33 20-70 29-110 29-40 0-77-9-110-29-34-20-60-46-80-80-20-33-29-70-29-110 0-40 9-77 29-110 20-34 46-60 80-80 33-20 70-29 110-29 40 0 77 9 110 29 34 20 60 46 80 80 20 33 29 70 29 110z\" transform=\"scale(0.046875 0.046875)\"><\/path><\/svg><\/div><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=bestcontact_42dce96ac8cd28f61abab34d43f0a5dc><input  type=\"radio\" name=\"bestcontact\" data-name=\"bestcontact\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Phone Call\"  id='bestcontact_42dce96ac8cd28f61abab34d43f0a5dc' aria-label='Phone Call' aria-invalid='false' aria-required=true> <span>Phone Call<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=bestcontact_ba94ca76ca18ccd00547651dc4128a8c><input  type=\"radio\" name=\"bestcontact\" data-name=\"bestcontact\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Email\"  id='bestcontact_ba94ca76ca18ccd00547651dc4128a8c' aria-label='Email' aria-invalid='false' aria-required=true> <span>Email<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=bestcontact_73c16311126610480e953ba83e6b4aef><input  type=\"radio\" name=\"bestcontact\" data-name=\"bestcontact\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Text\"  id='bestcontact_73c16311126610480e953ba83e6b4aef' aria-label='Text' aria-invalid='false' aria-required=true> <span>Text<\/span><\/label><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div class=\" fluentform-step\" data-name=\"form_step-5_6\" ><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_7\" ><h3 class='ff-el-section-title'>Household Information*<\/h3><div class='ff-section_break_desk'><p>List<strong> everyone<\/strong> that lives in your home.<\/p><\/div><hr \/><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_3 aa '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageMU5' aria-label=\"Males Under 5 Years\">Males Under 5 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageMU5\" id=\"ff_5_ageMU5\" class=\"ff-el-form-control\" data-name=\"ageMU5\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageFU5' aria-label=\"Females Under 5 Years\">Females Under 5 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageFU5\" id=\"ff_5_ageFU5\" class=\"ff-el-form-control\" data-name=\"ageFU5\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageM5t9' aria-label=\"Males 5-9 Years\">Males 5-9 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageM5t9\" id=\"ff_5_ageM5t9\" class=\"ff-el-form-control\" data-name=\"ageM5t9\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageF5t9' aria-label=\"Females 5-9 Years\">Females 5-9 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageF5t9\" id=\"ff_5_ageF5t9\" class=\"ff-el-form-control\" data-name=\"ageF5t9\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageM10t14' aria-label=\"Males 10-14 Years\">Males 10-14 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageM10t14\" id=\"ff_5_ageM10t14\" class=\"ff-el-form-control\" data-name=\"ageM10t14\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageF10t14' aria-label=\"Females 10-14 Years\">Females 10-14 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageF10t14\" id=\"ff_5_ageF10t14\" class=\"ff-el-form-control\" data-name=\"ageF10t14\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_3 aa '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageM15t17' aria-label=\"Males 15-17 Years\">Males 15-17 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageM15t17\" id=\"ff_5_ageM15t17\" class=\"ff-el-form-control\" data-name=\"ageM15t17\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageF15t17' aria-label=\"Females 15-17 Years\">Females 15-17 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageF15t17\" id=\"ff_5_ageF15t17\" class=\"ff-el-form-control\" data-name=\"ageF15t17\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageM18t24' aria-label=\"Males 18-24 Years\">Males 18-24 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageM18t24\" id=\"ff_5_ageM18t24\" class=\"ff-el-form-control\" data-name=\"ageM18t24\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageF18t24' aria-label=\"Females 18-24 Years\">Females 18-24 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageF18t24\" id=\"ff_5_ageF18t24\" class=\"ff-el-form-control\" data-name=\"ageF18t24\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageM25t34' aria-label=\"Males 25-34 Years\">Males 25-34 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageM25t34\" id=\"ff_5_ageM25t34\" class=\"ff-el-form-control\" data-name=\"ageM25t34\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageF25t34' aria-label=\"Females 25-34 Years\">Females 25-34 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageF25t34\" id=\"ff_5_ageF25t34\" class=\"ff-el-form-control\" data-name=\"ageF25t34\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_8\"  class='ff-t-container ff-column-container ff_columns_total_3 aa '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageM35t44' aria-label=\"Males 35-44 Years\">Males 35-44 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageM35t44\" id=\"ff_5_ageM35t44\" class=\"ff-el-form-control\" data-name=\"ageM35t44\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageF35t44' aria-label=\"Females 35-44 Years\">Females 35-44 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageF35t44\" id=\"ff_5_ageF35t44\" class=\"ff-el-form-control\" data-name=\"ageF35t44\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageM45t54' aria-label=\"Males 45-54 Years\">Males 45-54 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageM45t54\" id=\"ff_5_ageM45t54\" class=\"ff-el-form-control\" data-name=\"ageM45t54\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageF45t54' aria-label=\"Females 45-54 Years\">Females 45-54 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageF45t54\" id=\"ff_5_ageF45t54\" class=\"ff-el-form-control\" data-name=\"ageF45t54\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageM55t64' aria-label=\"Males 55-64 Years\">Males 55-64 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageM55t64\" id=\"ff_5_ageM55t64\" class=\"ff-el-form-control\" data-name=\"ageM55t64\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageF55t64' aria-label=\"Females 55-64 Years\">Females 55-64 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageF55t64\" id=\"ff_5_ageF55t64\" class=\"ff-el-form-control\" data-name=\"ageF55t64\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_9\"  class='ff-t-container ff-column-container ff_columns_total_3 aa '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageM65t84' aria-label=\"Males 65-84 Years\">Males 65-84 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageM65t84\" id=\"ff_5_ageM65t84\" class=\"ff-el-form-control\" data-name=\"ageM65t84\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageF65t84' aria-label=\"Females 65-84 Years\">Females 65-84 Years<\/label><\/div><div class='ff-el-input--content'><select name=\"ageF65t84\" id=\"ff_5_ageF65t84\" class=\"ff-el-form-control\" data-name=\"ageF65t84\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageM85U' aria-label=\"Males 85 Years and Over\">Males 85 Years and Over<\/label><\/div><div class='ff-el-input--content'><select name=\"ageM85U\" id=\"ff_5_ageM85U\" class=\"ff-el-form-control\" data-name=\"ageM85U\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_ageF85U' aria-label=\"Females 85 Years and Over\">Females 85 Years and Over<\/label><\/div><div class='ff-el-input--content'><select name=\"ageF85U\" id=\"ff_5_ageF85U\" class=\"ff-el-form-control\" data-name=\"ageF85U\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Number -<\/option><option value=\"1\"  >1<\/option><option value=\"2\"  >2<\/option><option value=\"3\"  >3<\/option><option value=\"4\"  >4<\/option><option value=\"5 or more\"  >5 or more<\/option><option value=\"NONE\"  >NONE<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><\/div><\/div><div class='step-nav ff_step_nav_last'><button  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div class=\" fluentform-step\" data-name=\"form_step-5_8\" ><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_9\" ><h3 class='ff-el-section-title'>MILITARY STATUS<\/h3><div class='ff-section_break_desk'><p>Please choose one <span style=\"color: #ff0000\">*<\/span><\/p><\/div><hr \/><\/div><div class='ff-el-group ff-el-form-hide_label  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Military Status\">Military Status<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=Military_8cd84905e297a79ff8f763a318b66692><input  type=\"radio\" name=\"Military\" data-name=\"Military\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Active Duty\"  id='Military_8cd84905e297a79ff8f763a318b66692' aria-label='Active Duty' aria-invalid='false' aria-required=true> <span>Active Duty<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=Military_0148b80945387fc60bf2c8d080e1a070><input  type=\"radio\" name=\"Military\" data-name=\"Military\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Retired\"  id='Military_0148b80945387fc60bf2c8d080e1a070' aria-label='Retired' aria-invalid='false' aria-required=true> <span>Retired<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=Military_7af405d92bce1cce62780b1caf63f542><input  type=\"radio\" name=\"Military\" data-name=\"Military\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Reserves\/Nat'l Guard\"  id='Military_7af405d92bce1cce62780b1caf63f542' aria-label='Reserves\/Nat&#039;l Guard' aria-invalid='false' aria-required=true> <span>Reserves\/Nat'l Guard<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=Military_1b27606ce23407c6cae90a50db7b6bf6><input  type=\"radio\" name=\"Military\" data-name=\"Military\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Veteran\"  id='Military_1b27606ce23407c6cae90a50db7b6bf6' aria-label='Veteran' aria-invalid='false' aria-required=true> <span>Veteran<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=Military_c02c810a1a251db2c62b182460ad0483><input  type=\"radio\" name=\"Military\" data-name=\"Military\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Did Not Serve\"  id='Military_c02c810a1a251db2c62b182460ad0483' aria-label='Did Not Serve' aria-invalid='false' aria-required=true> <span>Did Not Serve<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_10\" ><h3 class='ff-el-section-title'>PLEASE SELECT YOUR RACIAL CATEGORY<\/h3><div class='ff-section_break_desk'><p><span style=\"color: #ff0000\"><span style=\"color: #000000\">Please choose one <\/span>*<\/span><\/p><\/div><hr \/><\/div><div class='ff-el-group ff-el-form-hide_label  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Racial Category\">Racial Category<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=race_d9bf2711f1f3155e87ee5eb1f35bcf09><input  type=\"radio\" name=\"race\" data-name=\"race\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"White\"  id='race_d9bf2711f1f3155e87ee5eb1f35bcf09' aria-label='White' aria-invalid='false' aria-required=true> <span>White<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=race_6ee370719eec71206c538020f3cec676><input  type=\"radio\" name=\"race\" data-name=\"race\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Asian\"  id='race_6ee370719eec71206c538020f3cec676' aria-label='Asian' aria-invalid='false' aria-required=true> <span>Asian<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=race_11314f0eef59e9465290dc953699cc15><input  type=\"radio\" name=\"race\" data-name=\"race\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Black or African American\"  id='race_11314f0eef59e9465290dc953699cc15' aria-label='Black or African American' aria-invalid='false' aria-required=true> <span>Black or African American<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=race_c40821d556d7d061d8e8f6a674059b3b><input  type=\"radio\" name=\"race\" data-name=\"race\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Native American or Alaskan Native (Inuit)\"  id='race_c40821d556d7d061d8e8f6a674059b3b' aria-label='Native American or Alaskan Native (Inuit)' aria-invalid='false' aria-required=true> <span>Native American or Alaskan Native (Inuit)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=race_07bc67164298f527ea430bbde38f1098><input  type=\"radio\" name=\"race\" data-name=\"race\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Native Hawaiian or Other Pacific Islander\"  id='race_07bc67164298f527ea430bbde38f1098' aria-label='Native Hawaiian or Other Pacific Islander' aria-invalid='false' aria-required=true> <span>Native Hawaiian or Other Pacific Islander<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=race_4de72935d9f58505e9d2b91fb188a011><input  type=\"radio\" name=\"race\" data-name=\"race\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"One Race, Other\"  id='race_4de72935d9f58505e9d2b91fb188a011' aria-label='One Race, Other' aria-invalid='false' aria-required=true> <span>One Race, Other<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=race_c3264c889796f281f111bc4b6506dc30><input  type=\"radio\" name=\"race\" data-name=\"race\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Two or More Races, Other\"  id='race_c3264c889796f281f111bc4b6506dc30' aria-label='Two or More Races, Other' aria-invalid='false' aria-required=true> <span>Two or More Races, Other<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_11\" ><h3 class='ff-el-section-title'>PLEASE SELECT YOUR ETHNIC CATEGORY<\/h3><div class='ff-section_break_desk'><p>Please choose one <span style=\"color: #ff0000\">*<\/span><\/p><\/div><hr \/><\/div><div class='ff-el-group ff-el-form-hide_label  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Ethnic Category\">Ethnic Category<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=ethnic_cdf15e98bbc5b9da37f72ad8cc268c00><input  type=\"radio\" name=\"ethnic\" data-name=\"ethnic\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Hispanic or Latino\"  id='ethnic_cdf15e98bbc5b9da37f72ad8cc268c00' aria-label='Hispanic or Latino' aria-invalid='false' aria-required=true> <span>Hispanic or Latino<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=ethnic_994a917a0985969c137db1552b7ed3c2><input  type=\"radio\" name=\"ethnic\" data-name=\"ethnic\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Not Hispanic or Latino\"  id='ethnic_994a917a0985969c137db1552b7ed3c2' aria-label='Not Hispanic or Latino' aria-invalid='false' aria-required=true> <span>Not Hispanic or Latino<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_12\" ><h3 class='ff-el-section-title'>ARE YOU RECEIVING ANY ASSISTANCE?*<\/h3><div class='ff-section_break_desk'><p>Please <strong><span style=\"text-decoration: underline\">select ALL boxes<\/span><\/strong> that apply to ANY ASSISTANCE your family is receiving.<\/p><\/div><hr \/><\/div><div class='ff-el-group ff-el-form-hide_label  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Type of Assistance Received\">Type of Assistance Received<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=provider5incomesource_1813d19c3c73540673b237aca739234c><input  type=\"checkbox\" name=\"provider5incomesource[]\" data-name=\"provider5incomesource\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Child Support\"  id='provider5incomesource_1813d19c3c73540673b237aca739234c' aria-label='Child Support' aria-invalid='false' aria-required=true> <span>Child Support<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=provider5incomesource_3cd37058b3a306a0e9832e2c361b8228><input  type=\"checkbox\" name=\"provider5incomesource[]\" data-name=\"provider5incomesource\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"CHIP\"  id='provider5incomesource_3cd37058b3a306a0e9832e2c361b8228' aria-label='CHIP' aria-invalid='false' aria-required=true> <span>CHIP<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=provider5incomesource_458c136995390ca30d95e67a820190d9><input  type=\"checkbox\" name=\"provider5incomesource[]\" data-name=\"provider5incomesource\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"WIC\"  id='provider5incomesource_458c136995390ca30d95e67a820190d9' aria-label='WIC' aria-invalid='false' aria-required=true> <span>WIC<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=provider5incomesource_d1a701236c61ede71d87da7ce76dc8e7><input  type=\"checkbox\" name=\"provider5incomesource[]\" data-name=\"provider5incomesource\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"CSFP\"  id='provider5incomesource_d1a701236c61ede71d87da7ce76dc8e7' aria-label='CSFP' aria-invalid='false' aria-required=true> <span>CSFP<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=provider5incomesource_1cd4c8854165d081ea1bdc69e655e094><input  type=\"checkbox\" name=\"provider5incomesource[]\" data-name=\"provider5incomesource\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"FoodShare Wisconsin\"  id='provider5incomesource_1cd4c8854165d081ea1bdc69e655e094' aria-label='FoodShare Wisconsin' aria-invalid='false' aria-required=true> <span>FoodShare Wisconsin<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=provider5incomesource_7b5dd098003581c1dab93ba55808fa70><input  type=\"checkbox\" name=\"provider5incomesource[]\" data-name=\"provider5incomesource\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"SNAP (Food Stamps)\"  id='provider5incomesource_7b5dd098003581c1dab93ba55808fa70' aria-label='SNAP (Food Stamps)' aria-invalid='false' aria-required=true> <span>SNAP (Food Stamps)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=provider5incomesource_ddc4ec5150a544c3933bed6bffbbaf1b><input  type=\"checkbox\" name=\"provider5incomesource[]\" data-name=\"provider5incomesource\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"FMLA\"  id='provider5incomesource_ddc4ec5150a544c3933bed6bffbbaf1b' aria-label='FMLA' aria-invalid='false' aria-required=true> <span>FMLA<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=provider5incomesource_15b951ac03ed3f44d6ff4ffd59e1b243><input  type=\"checkbox\" name=\"provider5incomesource[]\" data-name=\"provider5incomesource\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Medicaid\"  id='provider5incomesource_15b951ac03ed3f44d6ff4ffd59e1b243' aria-label='Medicaid' aria-invalid='false' aria-required=true> <span>Medicaid<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=provider5incomesource_1d6e96339991db4b56ed271f5f8c542a><input  type=\"checkbox\" name=\"provider5incomesource[]\" data-name=\"provider5incomesource\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"SSI\"  id='provider5incomesource_1d6e96339991db4b56ed271f5f8c542a' aria-label='SSI' aria-invalid='false' aria-required=true> <span>SSI<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=provider5incomesource_c66b744aced9e4e1913a4700a66ca417><input  type=\"checkbox\" name=\"provider5incomesource[]\" data-name=\"provider5incomesource\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"SSDI\"  id='provider5incomesource_c66b744aced9e4e1913a4700a66ca417' aria-label='SSDI' aria-invalid='false' aria-required=true> <span>SSDI<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=provider5incomesource_819b9f32bb8f4102263115ffd307fa02><input  type=\"checkbox\" name=\"provider5incomesource[]\" data-name=\"provider5incomesource\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"VA Disability\"  id='provider5incomesource_819b9f32bb8f4102263115ffd307fa02' aria-label='VA Disability' aria-invalid='false' aria-required=true> <span>VA Disability<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=provider5incomesource_aaf491c86ed76f8ef20d55dedea3c685><input  type=\"checkbox\" name=\"provider5incomesource[]\" data-name=\"provider5incomesource\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"TANF\"  id='provider5incomesource_aaf491c86ed76f8ef20d55dedea3c685' aria-label='TANF' aria-invalid='false' aria-required=true> <span>TANF<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=provider5incomesource_fa2eda7fbef3fb2594c0a9bcaa9885ff><input  type=\"checkbox\" name=\"provider5incomesource[]\" data-name=\"provider5incomesource\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"WHEAP\"  id='provider5incomesource_fa2eda7fbef3fb2594c0a9bcaa9885ff' aria-label='WHEAP' aria-invalid='false' aria-required=true> <span>WHEAP<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=provider5incomesource_2c12888984f79fcb5fa027296b605213><input  type=\"checkbox\" name=\"provider5incomesource[]\" data-name=\"provider5incomesource\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"WisWAP\"  id='provider5incomesource_2c12888984f79fcb5fa027296b605213' aria-label='WisWAP' aria-invalid='false' aria-required=true> <span>WisWAP<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=provider5incomesource_afc44b999837c704e1ca854af1610977><input  type=\"checkbox\" name=\"provider5incomesource[]\" data-name=\"provider5incomesource\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Tribal Per Cap\"  id='provider5incomesource_afc44b999837c704e1ca854af1610977' aria-label='Tribal Per Cap' aria-invalid='false' aria-required=true> <span>Tribal Per Cap<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=provider5incomesource_aadb849a3e1faacf0dd07cf5ca725229><input  type=\"checkbox\" name=\"provider5incomesource[]\" data-name=\"provider5incomesource\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Workers Comp\"  id='provider5incomesource_aadb849a3e1faacf0dd07cf5ca725229' aria-label='Workers Comp' aria-invalid='false' aria-required=true> <span>Workers Comp<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=provider5incomesource_f786c7779c7e352893ee4a541a5629c5><input  type=\"checkbox\" name=\"provider5incomesource[]\" data-name=\"provider5incomesource\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"NONE\"  id='provider5incomesource_f786c7779c7e352893ee4a541a5629c5' aria-label='NONE' aria-invalid='false' aria-required=true> <span>NONE<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_13\" ><h3 class='ff-el-section-title'>EMPLOYMENT STATUS*<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Are you currently employed?\">Are you currently employed?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=empstatus_c0b0cf9dd3b3669d9b9de6387a3d1585><input  type=\"radio\" name=\"empstatus\" data-name=\"empstatus\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='empstatus_c0b0cf9dd3b3669d9b9de6387a3d1585' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=empstatus_6bc3d49eea2f80a212bb5b7ec590efe6><input  type=\"radio\" name=\"empstatus\" data-name=\"empstatus\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='empstatus_6bc3d49eea2f80a212bb5b7ec590efe6' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_14\" ><h3 class='ff-el-section-title'>TOTAL ANNUAL HOUSEHOLD INCOME*<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff-el-form-hide_label  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Total Income\">Total Income<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=income_7ba9324475118c4a510f7ba60f7ab929><input  type=\"checkbox\" name=\"income[]\" data-name=\"income\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Less than $10,000\"  id='income_7ba9324475118c4a510f7ba60f7ab929' aria-label='Less than $10,000' aria-invalid='false' aria-required=true> <span>Less than $10,000<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=income_721c7bca77959f955d0706c58d6b9778><input  type=\"checkbox\" name=\"income[]\" data-name=\"income\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"$10,000 - $19,999\"  id='income_721c7bca77959f955d0706c58d6b9778' aria-label='$10,000 - $19,999' aria-invalid='false' aria-required=true> <span>$10,000 - $19,999<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=income_cc9a66f8f7510395458c0bd14dc562b6><input  type=\"checkbox\" name=\"income[]\" data-name=\"income\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"$20,000 - $29,999\"  id='income_cc9a66f8f7510395458c0bd14dc562b6' aria-label='$20,000 - $29,999' aria-invalid='false' aria-required=true> <span>$20,000 - $29,999<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=income_e36e6b7215b50dd1089aaf84abe73452><input  type=\"checkbox\" name=\"income[]\" data-name=\"income\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"$30,000 - $39,999\"  id='income_e36e6b7215b50dd1089aaf84abe73452' aria-label='$30,000 - $39,999' aria-invalid='false' aria-required=true> <span>$30,000 - $39,999<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=income_a4085af926c89189e751d3583bde0385><input  type=\"checkbox\" name=\"income[]\" data-name=\"income\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"$40,000 - $49,999\"  id='income_a4085af926c89189e751d3583bde0385' aria-label='$40,000 - $49,999' aria-invalid='false' aria-required=true> <span>$40,000 - $49,999<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=income_10b96aa95d81d7d0202ba223757514a8><input  type=\"checkbox\" name=\"income[]\" data-name=\"income\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"$50,000 - $59,999\"  id='income_10b96aa95d81d7d0202ba223757514a8' aria-label='$50,000 - $59,999' aria-invalid='false' aria-required=true> <span>$50,000 - $59,999<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=income_1ec18f77971214d20a26a7a7ba37b410><input  type=\"checkbox\" name=\"income[]\" data-name=\"income\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"$60,000 - $69,999\"  id='income_1ec18f77971214d20a26a7a7ba37b410' aria-label='$60,000 - $69,999' aria-invalid='false' aria-required=true> <span>$60,000 - $69,999<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=income_27e34f65add55c096d7118aa9b49f864><input  type=\"checkbox\" name=\"income[]\" data-name=\"income\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"$70,000 - $79,999\"  id='income_27e34f65add55c096d7118aa9b49f864' aria-label='$70,000 - $79,999' aria-invalid='false' aria-required=true> <span>$70,000 - $79,999<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=income_080bcc7be5657c68046cbc138800e65e><input  type=\"checkbox\" name=\"income[]\" data-name=\"income\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"$80,000 - $89,999\"  id='income_080bcc7be5657c68046cbc138800e65e' aria-label='$80,000 - $89,999' aria-invalid='false' aria-required=true> <span>$80,000 - $89,999<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=income_5e12e1847fb07f117dc63af847a742e2><input  type=\"checkbox\" name=\"income[]\" data-name=\"income\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"$90,000 - $99,999\"  id='income_5e12e1847fb07f117dc63af847a742e2' aria-label='$90,000 - $99,999' aria-invalid='false' aria-required=true> <span>$90,000 - $99,999<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=income_ee79a99944380fb83dbb4544bb1645fb><input  type=\"checkbox\" name=\"income[]\" data-name=\"income\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"$100,000 - $124,999\"  id='income_ee79a99944380fb83dbb4544bb1645fb' aria-label='$100,000 - $124,999' aria-invalid='false' aria-required=true> <span>$100,000 - $124,999<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=income_61d8586a05e0e0ca2726b12e7bfecb49><input  type=\"checkbox\" name=\"income[]\" data-name=\"income\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"$125,000 - $149,999\"  id='income_61d8586a05e0e0ca2726b12e7bfecb49' aria-label='$125,000 - $149,999' aria-invalid='false' aria-required=true> <span>$125,000 - $149,999<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=income_e9e76ff0420aa1d23f5add9b1ef7b0d2><input  type=\"checkbox\" name=\"income[]\" data-name=\"income\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"$150,000 or more\"  id='income_e9e76ff0420aa1d23f5add9b1ef7b0d2' aria-label='$150,000 or more' aria-invalid='false' aria-required=true> <span>$150,000 or more<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=income_688d5d3909533d683a2f34aff0bcdb8c><input  type=\"checkbox\" name=\"income[]\" data-name=\"income\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"NONE\"  id='income_688d5d3909533d683a2f34aff0bcdb8c' aria-label='NONE' aria-invalid='false' aria-required=true> <span>NONE<\/span><\/label><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div class=\" fluentform-step\" data-name=\"form_step-5_15\" ><div data-name=\"ff_cn_id_10\"  class='ff-t-container ff-column-container ff_columns_total_1  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Was there an emergency situation which caused you to contact us?\">Was there an emergency situation which caused you to contact us?               <\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=emergencysituation_803d26850d6477c5d7c52d93a5aed488><input  type=\"radio\" name=\"emergencysituation\" data-name=\"emergencysituation\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='emergencysituation_803d26850d6477c5d7c52d93a5aed488' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=emergencysituation_5937717983f3a24dd8e1d545f08e626f><input  type=\"radio\" name=\"emergencysituation\" data-name=\"emergencysituation\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='emergencysituation_5937717983f3a24dd8e1d545f08e626f' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_explainemergency' aria-label=\"Briefly explain your current situation:\">Briefly explain your current situation: <\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=true name=\"explainemergency\" id=\"ff_5_explainemergency\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"explainemergency\" ><\/textarea><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_11\"  class='ff-t-container ff-column-container ff_columns_total_1  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_testimonial_1' aria-label=\"How will receiving personal and home cleaning products help you?\">How will receiving personal and home cleaning products help you?<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=true name=\"testimonial_1\" id=\"ff_5_testimonial_1\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"testimonial_1\" ><\/textarea><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_testimonial_2' aria-label=\"If you have received cleaning products from us in the past, how has receiving these products helped you?\">If you have received cleaning products from us in the past, how has receiving these products helped you?<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=false name=\"testimonial_2\" id=\"ff_5_testimonial_2\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"testimonial_2\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"May we use the information you have provided in the 2 questions above about HOW WILL and HOW DID receiving cleaning products help? ONLY the information from these 2 areas will be shared to help us show potential donors your need is real.\">May we use the information you have provided in the 2 questions above about HOW WILL and HOW DID receiving cleaning products help? ONLY the information from these 2 areas will be shared to help us show potential donors your need is real.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=testimonialapproval_1_b6a0706002cd4cae2506252ca2ad0904><input  type=\"radio\" name=\"testimonialapproval_1\" data-name=\"testimonialapproval_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='testimonialapproval_1_b6a0706002cd4cae2506252ca2ad0904' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=testimonialapproval_1_358b2dece3dd187862d562bfd81053e2><input  type=\"radio\" name=\"testimonialapproval_1\" data-name=\"testimonialapproval_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='testimonialapproval_1_358b2dece3dd187862d562bfd81053e2' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_16\" ><h3 class='ff-el-section-title'>CLIENT ACKNOWLEDGEMENT<\/h3><div class='ff-section_break_desk'><p><strong><em>I certify that I am a member of the household listed above, 18 years of age or older, and certify that all information regarding my household is true to the best of my knowledge.\u00a0\u00a0<\/em><\/strong><\/p><\/div><hr \/><\/div><div data-name=\"ff_cn_id_12\"  class='ff-t-container ff-column-container ff_columns_total_1  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-5_17\" ><p><strong>NOTE: Your answers on this form are important to help determine how to best serve you, and to obtain funding to support our programs.<\/strong><\/p><\/div><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-5_18\" ><h3 style=\"text-align: center\"><u>All applicants MUST sign this form digitally.<\/u><\/h3><\/div><\/div><\/div><div data-name=\"ff_cn_id_13\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_signature' aria-label=\"Client Signature\">Client Signature<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"signature\" class=\"ff-el-form-control\" placeholder=\"This field serves as your digital signature\" data-name=\"signature\" id=\"ff_5_signature\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_g2ndate' aria-label=\"Date\">Date<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='m\/d\/Y' type=\"text\" name=\"g2ndate\" value=\"02\/01\/2025\" id=\"ff_5_g2ndate\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"Date\" data-name=\"g2ndate\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_14\"  class='ff-t-container ff-column-container ff_columns_total_1  has-conditions '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-5_19\" ><h3 style=\"text-align: left\"><span style=\"color: #ff0000\">IMPORTANT - Another Required Form<\/span><\/h3><\/div><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-5_20\" ><p><strong>After you submit this form, the PRODUCT LIST will become available for you to complete.\u00a0<\/strong><\/p>\n<p><strong>The Product List tells us what cleaning products for personal care, baby care, or your home you are in need of.<\/strong><\/p><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Radio Field\">Radio Field<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_aefa8cff4d3249ed2741e7f998730ede><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_aefa8cff4d3249ed2741e7f998730ede' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_023aea4a9b69fe77fb8e952d679f895e><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_023aea4a9b69fe77fb8e952d679f895e' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div>        <div class=\"ff-step-t-container ff-inner_submit_container ff-column-container ff_columns_total_2\">\n            <div class=\"ff-t-cell ff-t-column-1\"><div class='step-nav ff_step_nav_last'><button  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><\/div><\/div>\n            <div class=\"ff-t-cell ff-t-column-2\">\n                <div class='ff-el-group ff-text-center ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-lg ff_btn_style\" >Submit Form<\/button><\/div>            <\/div>\n        <\/div>\n        <\/div><\/div><\/div>\n        <\/fieldset><\/form><div id='fluentform_5_errors' class='ff-errors-in-stack ff_form_instance_5_1 ff-form-loading_errors ff_form_instance_5_1_errors'><\/div><\/div>        <script type=\"text\/javascript\">\n            window.fluent_form_ff_form_instance_5_1 = {\"id\":\"5\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\",\"asteriskPlacement\":\"asterisk-right\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_5_1\",\"form_id_selector\":\"fluentform_5\",\"rules\":{\"at_giveaway\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"howlearned\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"personorg\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"titleposition\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"personname\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"otherinfo\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"usedservices_1\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"homeless\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"names[first_name]\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"names[middle_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is 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