{"id":11118,"date":"2023-06-26T19:04:55","date_gmt":"2023-06-26T19:04:55","guid":{"rendered":"https:\/\/www.stewartspoint.org\/wp2\/?page_id=11118"},"modified":"2023-06-26T19:04:55","modified_gmt":"2023-06-26T19:04:55","slug":"tribal-member-income-verification-form","status":"publish","type":"page","link":"https:\/\/www.stewartspoint.org\/wp2\/tribal-member-income-verification-form\/","title":{"rendered":"Tribal Member Income Verification Form"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-11111\"><form id=\"wpforms-form-11111\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"11111\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/wp2\/wp-json\/wp\/v2\/pages\/11118\" data-token=\"7873e5e6eaadb95dbec102910b780b5e\" data-token-time=\"1776781426\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-11111-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><label class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-11111-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" required><label for=\"wpforms-11111-field_1\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-11111-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" required><label for=\"wpforms-11111-field_1-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-11111-field_2-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-11111-field_2\">Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-11111-field_2\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][2]\" aria-label=\"Phone\" required><\/div><div id=\"wpforms-11111-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-11111-field_3\">Last 4 of Social Security Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-11111-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" required><\/div><div id=\"wpforms-11111-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-11111-field_4\">Time Period of Payments <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-11111-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" required><\/div><div id=\"wpforms-11111-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-11111-field_5\">How wants info Sent<\/label><input type=\"text\" id=\"wpforms-11111-field_5\" class=\"wpforms-field-medium\" name=\"wpforms[fields][5]\" ><\/div><div id=\"wpforms-11111-field_6-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-11111-field_6\">Fax #<\/label><input type=\"tel\" id=\"wpforms-11111-field_6\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][6]\" aria-label=\"Fax #\" ><\/div><div id=\"wpforms-11111-field_7-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"7\"><label class=\"wpforms-field-label\">Mailing Address <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-11111-field_7\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][7][address1]\" required><label for=\"wpforms-11111-field_7\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-11111-field_7-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][7][address2]\" ><label for=\"wpforms-11111-field_7-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-11111-field_7-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][7][city]\" required><label for=\"wpforms-11111-field_7-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-11111-field_7-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][7][state]\" required><option class=\"placeholder\" value=\"\" selected disabled>--- Select state ---<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-11111-field_7-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-11111-field_7-postal\" class=\"wpforms-field-address-postal wpforms-field-required wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][7][postal]\" required><label for=\"wpforms-11111-field_7-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-11111-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-11111-field_8\">Attention<\/label><input type=\"text\" id=\"wpforms-11111-field_8\" class=\"wpforms-field-medium\" name=\"wpforms[fields][8]\" ><\/div><div id=\"wpforms-11111-field_10-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-11111-field_10\">Date Received<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-11111-field_10\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][10][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"11111\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/www.stewartspoint.org\/wp2\/wp-json\/wp\/v2\/pages\/11118\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-11111\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/www.stewartspoint.org\/wp2\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  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