{"id":162,"date":"2014-07-10T02:02:34","date_gmt":"2014-07-10T02:02:34","guid":{"rendered":"http:\/\/creditfirm.net\/signup\/?page_id=162"},"modified":"2022-08-22T10:48:51","modified_gmt":"2022-08-22T16:48:51","slug":"couples","status":"publish","type":"page","link":"https:\/\/creditfirm.net\/signup\/couples\/","title":{"rendered":""},"content":{"rendered":"<h2 style=\"text-align: center;\">Credit Repair Service Enrollment Form For Couples<\/h2>\r\n<p style=\"text-align: center;\">Click\u00a0<a href=\"https:\/\/creditfirm.net\/signup\/\">Here<\/a>\u00a0To Sign Up Individually<\/p>\r\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_10' ><div id='gf_10' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_10' id='gform_10'  action='\/signup\/wp-json\/wp\/v2\/pages\/162#gf_10' data-formid='10' novalidate><div id='gf_page_steps_10' class='gf_page_steps'><div id='gf_step_10_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'>Personal Information<\/span><\/div><div id='gf_step_10_2' class='gf_step gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'>Payment Information<\/span><\/div><div id='gf_step_10_3' class='gf_step gf_step_last gf_step_pending'><span class='gf_step_number'>3<\/span><span class='gf_step_label'>Legal Agreements<\/span><\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_10_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_10' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_10_1\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_1'>What is your Goal?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_10_1'>Example: Buy a House, Refinance, 640 FICO, etc...)<\/div><div class='ginput_container ginput_container_text'><input name='input_1' id='input_10_1' type='text' value='' class='medium'  aria-describedby=\"gfield_description_10_1\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_44\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_44'>What is your Spouse&#039;s Goal?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_10_44'>Example: Buy a House, Refinance, 640 FICO, etc...)<\/div><div class='ginput_container ginput_container_text'><input name='input_44' id='input_10_44' type='text' value='' class='medium'  aria-describedby=\"gfield_description_10_44\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_2\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_10_3\" class=\"gfield gfield--type-name gfield--input-type-name gf_left_half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Your Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_10_3'>\n                            \n                            <span id='input_10_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_10_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_3.3' id='input_10_3_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_10_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_10_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_3.6' id='input_10_3_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/li><li id=\"field_10_40\" class=\"gfield gfield--type-name gfield--input-type-name gf_right_half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Spouse&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_10_40'>\n                            \n                            <span id='input_10_40_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_10_40_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_40.3' id='input_10_40_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_10_40_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_10_40_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_40.6' id='input_10_40_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/li><li id=\"field_10_4\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_10_7\" class=\"gfield gfield--type-email gfield--input-type-email gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_7'>Your Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_10_7' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_10_41\" class=\"gfield gfield--type-email gfield--input-type-email gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_41'>Spouse&#039;s Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_41' id='input_10_41' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_10_8\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_8'>Your Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_10_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_42\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_42'>Spouse&#039;s Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_10_42' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_6\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_10_9\" class=\"gfield gfield--type-address gfield--input-type-address gf_left_half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Your Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_10_9' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_10_9_1_container' >\n                                        <label for='input_10_9_1' id='input_10_9_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_9.1' id='input_10_9_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_10_9_3_container' >\n                                    <label for='input_10_9_3' id='input_10_9_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_9.3' id='input_10_9_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_10_9_4_container' >\n                                        <label for='input_10_9_4' id='input_10_9_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                        <select name='input_9.4' id='input_10_9_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_10_9_5_container' >\n                                    <label for='input_10_9_5' id='input_10_9_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                    <input type='text' name='input_9.5' id='input_10_9_5' value=''    aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_9.6' id='input_10_9_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_10_43\" class=\"gfield gfield--type-address gfield--input-type-address gf_right_half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Spouse&#039;s Address<\/label>    <div id='input_10_43_copy_values_option_container' class='copy_values_option_container' >\n                                        <input type='checkbox' id='input_10_43_copy_values_activated' class='copy_values_activated' value='1' data-source_field_id='9' name='input_43_copy_values_activated'  \/>\n                                        <label for='input_10_43_copy_values_activated' id='input_10_43_copy_values_option_label' class='copy_values_option_label inline gform-field-label gform-field-label--type-inline'>Same as your address<\/label>\n                                    <\/div>\n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_10_43' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_10_43_1_container' >\n                                        <label for='input_10_43_1' id='input_10_43_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_43.1' id='input_10_43_1' value=''    aria-required='false'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_10_43_3_container' >\n                                    <label for='input_10_43_3' id='input_10_43_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_43.3' id='input_10_43_3' value=''    aria-required='false'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_10_43_4_container' >\n                                        <label for='input_10_43_4' id='input_10_43_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                        <select name='input_43.4' id='input_10_43_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_10_43_5_container' >\n                                    <label for='input_10_43_5' id='input_10_43_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                    <input type='text' name='input_43.5' id='input_10_43_5' value=''    aria-required='false'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_43.6' id='input_10_43_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='image' src='http:\/\/creditfirm.net\/signup\/wp-content\/uploads\/2014\/04\/step-2.png' id='gform_next_button_10_12' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' class='gform_next_button gform-theme-button button gform_image_button' alt='Next Page'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_10_2' class='gform_page' data-js='page-field-id-12' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_10_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_10_51\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-full wp-image-82\" src=\"https:\/\/creditfirm.net\/signup\/wp-content\/uploads\/2016\/01\/cfsuptop6999.png\" alt=\"cfsup2top69\" width=\"698\" height=\"200\" \/><\/li><li id=\"field_10_47\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield_price gfield_price_10_47 gfield_product_10_47 field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_10_47_1'>Monthly Service Fee (2 People)<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_47.1' value='Monthly Service Fee (2 People)' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_10_47' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_47.2' id='ginput_base_price_10_47' value='$89.99' aria-label='Monthly Service Fee (2 People) Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_47.3' value='1' class='ginput_quantity_10_47 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_10_58\" class=\"gfield gfield--type-creditcard gfield--input-type-creditcard gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_10_58_1'>Credit\/Debit Card<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_creditcard gform-grid-row' id='input_10_58'><span class='ginput_full gform-grid-col' id='input_10_58_1_container' >\n                                    <div class='gform_card_icon_container'><div class='gform_card_icon gform_card_icon_mastercard' >MasterCard<\/div><div class='gform_card_icon gform_card_icon_visa' >Visa<\/div><span class='screen-reader-text' id='field_10_58_supported_creditcards'>Supported Credit Cards: MasterCard, Visa<\/span><\/div>\n                                    <label for='input_10_58_1' id='input_10_58_1_label' class='gform-field-label gform-field-label--type-sub '>Card Number<\/label>\n                                    <input type='text' name='input_58.1' id='input_10_58_1' value=''   onchange='gformMatchCard(\"input_10_58_1\");' onkeyup='gformMatchCard(\"input_10_58_1\");' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='true'  \/>\n                                 <\/span><span class='ginput_full ginput_cardextras gform-grid-col gform-grid-row' id='input_10_58_2_container'>\n                                            <span class='ginput_cardinfo_left gform-grid-col' id='input_10_58_2_cardinfo_left'>\n                                            <label for='input_10_58_2_month' class='gform-field-label gform-field-label--type-sub '>Expiration Date<\/label>\n                                                <span class='ginput_card_expiration_container ginput_card_field gform-grid-row'>\n                                                   \n                                                       \n                                                       <select name='input_58.2[]' id='input_10_58_2_month'   class='ginput_card_expiration ginput_card_expiration_month' aria-required='true'  >\n                                                           <option value=''>Month<\/option><option value='1' >01<\/option><option value='2' >02<\/option><option value='3' >03<\/option><option value='4' >04<\/option><option value='5' >05<\/option><option value='6' >06<\/option><option value='7' >07<\/option><option value='8' >08<\/option><option value='9' >09<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option>\n                                                       <\/select>\n                                                   \n                                                   \n                                                       \n                                                       <select name='input_58.2[]' id='input_10_58_2_year'   class='ginput_card_expiration ginput_card_expiration_year' aria-required='true'  >\n                                                           <option value=''>Year<\/option><option value='2026' >2026<\/option><option value='2027' >2027<\/option><option value='2028' >2028<\/option><option value='2029' >2029<\/option><option value='2030' >2030<\/option><option value='2031' >2031<\/option><option value='2032' >2032<\/option><option value='2033' >2033<\/option><option value='2034' >2034<\/option><option value='2035' >2035<\/option><option value='2036' >2036<\/option><option value='2037' >2037<\/option><option value='2038' >2038<\/option><option value='2039' >2039<\/option><option value='2040' >2040<\/option><option value='2041' >2041<\/option><option value='2042' >2042<\/option><option value='2043' >2043<\/option><option value='2044' >2044<\/option><option value='2045' >2045<\/option>\n                                                       <\/select>\n                                                   \n                                                <\/span>\n                                            <\/span><span class='ginput_cardinfo_right gform-grid-col' id='input_10_58_2_cardinfo_right'>\n                                                <label for='input_10_58_3' class='gform-field-label gform-field-label--type-sub '>Security Code<\/label>\n                                                <input type='text' name='input_58.3' id='input_10_58_3'   class='ginput_card_security_code' value='' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='true'  \/>\n                                                <span class='ginput_card_security_code_icon'>&nbsp;<\/span>\n                                             <\/span>\n                                        <\/span><span class='ginput_full gform-grid-col' id='input_10_58_5_container'>\n                                            <label for='input_10_58_5' id='input_10_58_5_label' class='gform-field-label gform-field-label--type-sub '>Cardholder Name<\/label>\n                                            <input type='text' name='input_58.5' id='input_10_58_5' value=''    aria-required='false'  \/>\n                                        <\/span> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='image' src='https:\/\/creditfirm.net\/signup\/wp-content\/uploads\/2014\/04\/blank.png' id='gform_previous_button_10_22' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' class='gform_previous_button gform-theme-button gform-theme-button--secondary button gform_image_button' alt='Previous Page'  \/> <input type='image' src='https:\/\/creditfirm.net\/signup\/wp-content\/uploads\/2014\/04\/step-3.png' id='gform_next_button_10_22' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' class='gform_next_button gform-theme-button button gform_image_button' alt='Next Page'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_10_3' class='gform_page' data-js='page-field-id-22' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_10_3' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_10_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Federal Disclosure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_10_23'><li class='gchoice gchoice_10_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Accept'  id='choice_10_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_23_1' id='label_10_23_1' class='gform-field-label gform-field-label--type-inline'>Accept<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_10_24\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf_scroll_text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Federal Disclosure Statement<\/h2><div class='gsection_description' id='gfield_description_10_24'>Consumer Credit File Rights Under State and Federal Law<\/br> You have a right to dispute inaccurate information in your credit report by contacting the credit bureau directly. However, neither you nor any ''credit repair'' company or credit repair organization has the right to have accurate, current, and verifiable information removed from your credit report. The credit bureau must remove accurate, negative information from your report only if it is over 7 years old. Bankruptcy information can be reported for 10 years. You have a right to obtain a copy of your credit report from a credit bureau. You may be charged a reasonable fee. There is no fee, however, if you have been turned down for credit, employment, insurance, or a rental dwelling because of information in your credit report within the preceding 60 days. The credit bureau must provide someone to help you interpret the information in your credit file. You are entitled to receive a free copy of your credit report if you are unemployed and intend to apply for employment in the next 60 days, if you are a recipient of public welfare assistance, or if you have reason to believe that there is inaccurate information in your credit report due to fraud. You have a right to sue a credit repair organization that violates the Credit Repair Organization Act. This law prohibits deceptive practices by credit repair organizations. You have the right to cancel your contract with any credit repair organization for any reason within 3 business days from the date you signed it. Credit bureaus are required to follow reasonable procedures to ensure that the information they report is accurate. However, mistakes may occur. You may, on your own, notify a credit bureau in writing that you dispute the accuracy of information in your credit file. The credit bureau must then reinvestigate and modify or remove inaccurate or incomplete information. The credit bureau may not charge any fee for this service. Any pertinent information and copies of all documents you have concerning an error should be given to the credit bureau. If the credit bureau's reinvestigation does not resolve the dispute to your satisfaction, you may send a brief statement to the credit bureau, to be kept in your file, explaining why you think the record is inaccurate. The credit bureau must include a summary of your statement about disputed information with any report it issues about you. The Federal Trade Commission regulates credit bureaus and credit repair organizations. <\/br>For more information contact: <\/br>The Public Reference Branch <\/br>Federal Trade Commission <\/br>Washington, D.C. 20580'.<\/br><\/br> AZ, AR, DE(1), IN, IL(5), MA, MD, MO, NB, OK, OR, NH, PA(5), TX(5), WA, UT: Regarding Credit Bureaus: (1) The credit bureau must provide a complete and accurate statement of the consumer's right to review any file, as reported in the Fair Credit Reporting Act (15 USC \u00a7 1681 et seq); (2) the credit bureau must provide a statement that a review at no charge will be conducted on the consumer's credit report from which a credit denial is based if requested within thirty (30) days of the consumer receiving a notice of credit denial; (3) the credit bureau must provide the approximate price the consumer will be charged for a copy of his or her credit report; (4) the credit bureau must provide a complete and accurate statement of the consumer's right to dispute the completeness and accuracy of any item contained in any file on the consumer maintained by the credit bureau; Regarding Credit Services Organizations and CreditFirm.net: (5) CreditFirm.net provides a complete and detailed description of the services performed and the total fees charged by CreditFirm.net within the Credit Report Audit Verification, Service Agreement accompanying this disclosure statement, and by this reference, made a part of this Disclosure Statement. CA, IN(4), KS(4), LA(4), MO(4), NB(4), WV(4): Regarding Credit Bureaus: (1) You may be charged a reasonable fee not exceeding eight dollars ($8) for a credit report; Regarding Credit Services Organizations and CreditFirm.net: (2) Neither you nor any credit services organization has the right to have accurate, current, and verifiable information removed from your credit report; (2) If for any reason, you cancel the Service Agreement with the credit services organization within the three days from the date you signed the Service Agreement, you do not owe any money; (3) You have a right to sue a credit services organization if it misleads you; (4) You have the right to obtain the services of a nonprofit credit counseling service which may be able to assist you in your credit matters. CO: Regarding Credit Bureaus: (1) Even when a debt has been completely repaid, your credit report can reflect that the debt was paid late if that is accurate. FL, KS, MD, MO, NB, and WV: Regarding Credit Services Organization and CreditFirm.net: Accurate information cannot be permanently removed from the files of a credit bureau. IL, KS, MD, MA: Regarding Credit Bureaus: You have the right to review your credit report at no charge if a request is made to the credit bureau within thirty days after receipt by you of notice that credit has been denied. If such request is not made within the allotted time, the credit bureau must provide the approximate charge to you for a copy of your credit report for your review (For MD residents, a maximum fee of $5 may be charged). NY: Regarding Credit Bureaus: If reinvestigation of your report by the credit bureau does not resolve the dispute to your satisfaction, you may enter a statement of one hundred words or less in your file, explaining why you think the record is inaccurate. The credit bureau must include your statement about disputed data - or a coded version of it - with any reports it issues about you. New York law also provides that, at your request, the credit bureau must notify any person who has received a report in the previous year that an error existed and furnish such person with the corrected information. TIME LIMITS ON ADVERSE DATA: Most kinds of information in your file may be reported for a period of seven years. If you have declared personal bankruptcy, however, that fact may be reported for ten years. After seven or ten years, the information can't be disclosed by a credit bureau unless you are being investigated for a credit application of $50,000 or more, for an application to purchase life insurance of $50,000 or more, or for employment at an annual salary of $25,000 or more.<\/div><\/li><li id=\"field_10_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >State and Federal Cancellation Forms<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_10_25'><li class='gchoice gchoice_10_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Accept'  id='choice_10_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_25_1' id='label_10_25_1' class='gform-field-label gform-field-label--type-inline'>Accept<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_10_26\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf_scroll_text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Notice of Cancellation<\/h2><div class='gsection_description' id='gfield_description_10_26'>Notice of Cancellation<\/br><\/br>\n\nYou may cancel this agreement, without any penalty or obligation, within five days after the date the agreement is signed.<\/br><\/br>\nIf you cancel, any payment made by you, under this agreement, will be returned within 10 days after the date of receipt by CreditFirm.net of your cancellation notice.<\/br><\/br>\nTo cancel this contract, mail or deliver a signed, dated copy of this cancellation notice, or other written notice to:\u00a0CreditFirm.net at 1020 Milwaukee Ave, Suite 122, Deerfield, IL 60015, not later than midnight of the fifth business day after the agreement was signed.<\/br><\/br>\n\nI hereby cancel this transaction.<\/br>\n___________________________<\/br>              \nSignature<\/br>\n___________________________<\/br>              \nDate<\/br><\/br>\n\nNotice of Cancellation<\/br><\/br>\n\nYou may cancel this agreement, without any penalty or obligation, within five days after the date the agreement is signed.<\/br><\/br>\nIf you cancel, any payment made by you, under this agreement, will be returned within 10 days after the date of receipt by CreditFirm.net of your cancellation notice.<\/br><\/br>\nTo cancel this contract, mail or deliver a signed, dated copy of this cancellation notice, or other written notice to:\u00a0CreditFirm.net at 1020 Milwaukee Ave, Suite 122, Deerfield, IL 60015, not later than midnight of the fifth business day after the agreement was signed.<\/br><\/br>\n\nI hereby cancel this transaction.<\/br>\n___________________________<\/br>              \nSignature<\/br>\n___________________________<\/br>              \nDate<\/br><\/br><\/div><\/li><li id=\"field_10_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Credit Repair Agreement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_10_27'><li class='gchoice gchoice_10_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Accept'  id='choice_10_27_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_27_1' id='label_10_27_1' class='gform-field-label gform-field-label--type-inline'>Accept<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_10_56\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf_scroll_text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Credit Repair Agreement<\/h2><div class='gsection_description' id='gfield_description_10_56'>A - This agreement between Confident Corp D\/b\/a CreditFirm.net (COMPANY) and the undersigned (CLIENTS) is for the express purpose of credit report intervention. COMPANY will attempt the removal of errors, misrepresentations, or unverifiable information that the clients claim to appear on the credit report(s) they have furnished COMPANY. This is not a debt consolidation or bill payment program. Federal law requires that any unverifiable, outdated or erroneous information must be removed, regardless of accuracy. COMPANY agrees to act diligently in the pursuit of this matter, and will carry out this agreement within all Federal and States laws. Company reserves the right to withdraw from representing you if you breach this Contract or for any reason permitted under applicable professional rules of conduct. In the event Company withdraws, you agree to pay Company for the services rendered previous to the date of withdrawal. <\/br><\/br>\n\nB - The clients understand that there will not be any fee or other charges associated with the service until after the service is performed. Company performs one or more of the following services before you pay: enters your personal data into its secure database; enters one or more credit reports into its secure database; collects information and instructions from you regarding your particular circumstances and how you wish to proceed; analyzes your case; prepares and sends one or more Communications on your behalf.<\/br><\/br>\n\nSubsequently, Company typically performs one or more of the following ongoing and periodic services as appropriate in its judgment and discretion: receives and reviews Bureau and Furnisher correspondence sent to us directly or by you; collects and reviews updated information and instructions from you regarding your circumstances, goals, and case; monitors and analyzes your case; provides you with status updates regarding your case; and prepares and sends one or more additional Communications on your behalf.<\/br><\/br>\n\nFees are collected on a periodic basis, but only for services previously provided. Because fees are charged after rendering services, fees are generally not refundable.<\/br>\n\nA First Work Fee of $89.99 is charged five days from the date of this Contract. This fee will be charged after related services have been fully rendered.<\/br>\n\nWhen you elect to continue our services, you will be charged $89.99 at the end of each service interval, for work previously and fully rendered. Charges will be processed on or about the same day of each month for each service interval until you elect to suspend or cancel service. <\/br>\n\nC - The client agrees to send all correspondence and credit reports to COMPANY, as soon as received.<\/br>\nThe client must notify COMPANY if they have not received any credit reports or correspondence from the credit reporting agencies 40 days after the last correspondence from COMPANY or the credit reporting agencies. Failure to do so will cause the client's Credit Verification to be delayed.<\/br><\/br>\n\nD - Term of this agreement shall be: Month to Month\/ Cancel any time. You are advised to review your case at least each month and determine whether you wish to continue Company\u2019s services or suspend or cancel them.<\/br><\/br>\n\nE - Due to the nature of this credit service, client understands that individuals that assist COMPANY in this matter may view client's file and its contents. All people such as legal or research assistants and secretaries have been alerted to the sensitivity of these documents. COMPANY'S staff will take all reasonable measures to ensure that this information will be handled in a responsible manner.<\/br><\/br>\n\nF - I, the undersigned client, give Power of Attorney to COMPANY, for the sole purpose of acquiring, request typing verification, and disputing any information in regards to my credit report(s). By signing this document, I acknowledge receiving my \"Consumer Credit File Rights Under State & Federal Law, and my agreement cancellation form.<\/br><\/br>\n\nG - Client has executed a power of attorney to COMPANY to create and sign correspondence on Client\u2019s behalf to communicate Client\u2019s claims of inaccurate, untimely or unverifiable information to the credit bureaus. COMPANY provides an audit verification letter writing service which Challenges negative items on Client\u2019s's credit reports. Client Understands and agrees that COMPANY does not guarantee that any verified accurate item can or will be removed from Client\u2019s credit report. Client understands and agrees that dispute letters drafted, signed and mailed on your behalf and\/or in your name by COMPANY are proprietary to COMPANY and will not be kept as part of your client file and will not be disclosed to Client.<\/br><\/br>\n\nH - Clients understand that if one of individuals enrolled in the couples program for $89.95 per month cancels service, the remaining client, still enrolled in the program, will be placed on the individual plan for $49.95 per month.<\/br><\/br>\n\nCompany representatives may have discuss your case with you and in doing so may provide their opinions regarding your options as well as possible outcomes, given the information you provide to Company. Any expressions of opinion are not a guarantee and may not reflect an actual outcome.<\/br><\/br>\n\nArbitration. All claims and disputes arising under or relating to this Agreement are to be settled by binding arbitration in the state of Illinois or another location mutually agreeable to the parties. The arbitration shall be conducted on a confidential basis pursuant to the Commercial Arbitration Rules of the American Arbitration Association. Any decision or award as a result of any such arbitration proceeding shall be in writing and shall provide an explanation for all conclusions of law and fact and shall include the assessment of costs, expenses, and reasonable attorneys' fees. Any such arbitration shall be conducted by an arbitrator experienced in Credit Repair and shall include a written record of the arbitration hearing. The parties reserve the right to object to any individual who shall be employed by or affiliated with a competing organization or entity. <\/br><\/br>\n\nLimitation of Liability. COMPANY'S aggregate monetary liability for violations of this Agreement will not exceed an amount equal to the Fees paid by CLIENT to COMPANY within the preceding twelve-month period pursuant to this Agreement. In no event shall either party be liable for special, punitive, exemplary or consequential damages arising out of or in connection with this Agreement or the performance or nonperformance of this Agreement. <\/br><\/br>\n\nBILLING DISPUTES \u2013 CHARGEBACKS<\/br>\nDo not contact your bank or Credit Card Company in an attempt to obtain a refund. While your bank or credit card company may provide a temporary 'provisional credit' of the disputed amount, please be advised that COMPANY is successful in reversing the vast majority of chargebacks. In addition to the original charge, you accept responsibility for fees associated with the processing and follow up of the dispute. These costs range from $50.00 to $150.00. COMPANY reserves the right to collect these fees via the original payment method or through third party collection. COMPANY strives to exceed member expectation and provide Outstanding Customer Service. If you feel you are entitled to a full or partial please contact COMPANY for details regarding our Refund Policies and Procedures. 1-800-750-1416 Mon - Fri 9:00 am through 7:00 pm (CST)\n                    <\/div><\/li><li id=\"field_10_29\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Digital Signature<\/h2><div class='gsection_description' id='gfield_description_10_29'>E-sign grants electronic signatures and documents equivalent legal status as traditional handwritten signatures. By completing our Enrollment you are digitally agreeing to The Service Agreement and you are certifying that your digital signature is the equivalent of your handwritten signature. Furthermore, you agree that you have read all of the Terms and Conditions and the Agreement and are signing each section of the Agreement with your digital signature. You further agree that you understand the Agreement and have read \"Your Rights as a Consumer\".<\/div><\/li><li id=\"field_10_30\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_30'>Your Social Security Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_10_30' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_48\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_48'>Spouse&#039;s Social Security Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_10_48' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_37\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_10_32\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_32'>Your Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_10_32' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_49\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_49'>Spouse&#039;s Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_10_49' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_10_34\" class=\"gfield 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