---
FieldType: Button
FieldName: undefined
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_2
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_3
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: South Dakota 1000
FieldNameAlt: South Dakota ($10.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_4
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Kentucky 4000
FieldNameAlt: Kentucky ($40.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_5
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_6
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_7
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_8
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_9
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_10
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_11
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_12
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: North Carolina
FieldNameAlt: North Carolina
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Cancer Plan 1000
FieldNameAlt: Cancer Plan ($10.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Health 1000
FieldNameAlt: Health ($10.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Life 1000
FieldNameAlt: Life ($10.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Utah 000_2
FieldNameAlt: Utah ($0.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Connecticut 8000
FieldNameAlt: Connecticut ($80.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Maryland 000
FieldNameAlt: Maryland ($0.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: North Dakota 1000
FieldNameAlt: North Dakota ($10.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Vermont 6000
FieldNameAlt: Vermont ($60.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_13
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_14
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Ohio 000
FieldNameAlt: Ohio** ($0.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Health 1500
FieldNameAlt: Health ($15.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Life 1500
FieldNameAlt: Life ($15.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_15
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Georgia 1000
FieldNameAlt: Georgia ($10.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Michigan 1000
FieldNameAlt: Michigan ($10.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Oklahoma 3000
FieldNameAlt: Oklahoma ($30.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Washington 2000
FieldNameAlt: Washington ($20.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_16
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Mississippi 2500
FieldNameAlt: Mississippi ($25.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_17
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: West Virginia  2500
FieldNameAlt: West Virginia ($ 25.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_18
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_19
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_20
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Wisconsin 1600
FieldNameAlt: Wisconsin ($16.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Indiana 000
FieldNameAlt: Indiana ($0.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Montana 000
FieldNameAlt: Montana ($0.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Rhode Island 000
FieldNameAlt: Rhode Island ($0.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Wyoming  1500
FieldNameAlt: Wyoming ($ 15.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: undefined_21
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: Nebraska 800
FieldNameAlt: Nebraska ($8.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Button
FieldName: South Carolina 000
FieldNameAlt: South Carolina ($0.00
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On
---
FieldType: Text
FieldName: How did you hear about Equitable
FieldNameAlt: How did you hear about Equitable
FieldFlags: 0
FieldJustification: Left
---
FieldType: Text
FieldName: Please Explain
FieldNameAlt: Please Explain
FieldFlags: 0
FieldJustification: Left
---
FieldType: Text
FieldName: State Appointment Type AmountRow1
FieldNameAlt: State Appointment Type Amount_Row_1
FieldFlags: 0
FieldJustification: Center
---
FieldType: Text
FieldName: State Appointment Type AmountRow2
FieldNameAlt: State Appointment Type Amount_Row_2
FieldFlags: 0
FieldJustification: Center
---
FieldType: Text
FieldName: State Appointment Type AmountRow3
FieldNameAlt: State Appointment Type Amount_Row_3
FieldFlags: 0
FieldJustification: Center
---
FieldType: Text
FieldName: Text1
FieldFlags: 0
FieldJustification: Left
---
FieldType: Text
FieldName: The total amount of
FieldNameAlt: The total amount of
FieldFlags: 0
FieldJustification: Left
---
FieldType: Text
FieldName: will be electronically transferred from your checking account ending in
FieldNameAlt: will be electronically transferred from your checking account ending in
FieldFlags: 0
FieldJustification: Left
---
FieldType: Text
FieldName: as a onetime payment for appointment fees
FieldNameAlt: as a one-time payment for appointment fees
FieldFlags: 0
FieldJustification: Left
---
FieldType: Text
FieldName: Upon appointment I
FieldNameAlt: Upon appointment, I
FieldFlags: 0
FieldJustification: Left
---
FieldType: Text
FieldName: Above account as a onetime payment of appointment fees in the amountof
FieldNameAlt: Above account as a one-time payment of appointment fees in the amountof
FieldFlags: 0
FieldJustification: Left
---
FieldType: Text
FieldName: undefined_22
FieldNameAlt: undefined
FieldFlags: 0
FieldJustification: Left
---
FieldType: Button
FieldName: I Agree
FieldNameAlt: I Agree
FieldFlags: 0
FieldJustification: Left
FieldStateOption: Off
FieldStateOption: On