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<?php
session_start();
$SESSION_PAGE = "questionnaire";
$_SESSION['last_page'] = $SESSION_PAGE;
$body_id = 'quest';
$title = 'Confidential Questionnaire';
require_once('binx/includes/odds/header.php');
require_once('binx/php/functions.php');
require_once('binx/php/global_arrays.php');
$PRESONAL_INFO_QRY = $db->query("SELECT * FROM Members WHERE username = '$USERNAME' AND username != ''");
$PIR = $PRESONAL_INFO_QRY[0];
$BENEFICIARY_QRY = $db->query("SELECT * FROM Recipients WHERE username = '$USERNAME' AND ( relationship = 'Daughter' OR relationship = 'Father' OR relationship = 'Son' OR relationship = 'Mother' OR relationship = 'Foster Child' OR relationship = 'Foster Parent' OR relationship = 'Step Mother' OR relationship = 'Step Father' OR relationship = 'Step Son' OR relationship = 'Step Daughter' ) AND username != ''");
$ASSETS_QRY = $db->query("SELECT * FROM Assets WHERE username = '$USERNAME' AND username != ''");
$ASSETS = $ASSETS_QRY[0];
?>
<script type="text/javascript" src="https://ajax.googleapis.com/ajax/libs/jquery/1.6.0/jquery.min.js"></script>
<script language="javascript" type="text/javascript" src="../inc/script.js"></script>
<script>
function numbers_only(evt)
{
var charCode = (evt.which) ? evt.which : event.keyCode;
//alert(charCode);
if (evt.shiftKey)
{
return false;
}
if(charCode == 16)
{
return false;
}
if (charCode > 9 && (charCode < 48 || charCode > 57) && charCode != 46 && charCode != 37 && charCode != 39)
{
if(charCode <= 105 && charCode >= 96 && charCode != 16)
{
return true;
}
else
{
return false;
}
}
else
{
return true;
}
}
function submit_questionnaire()
{
if($('#id-client-your-signature-').val() == "")
{
alert("Please sign the questionnaire.");
}
else
{
if($('#id-spouse-first-name-').val() != "")
{
if($('#id-client-spouse-signature-').val() == "")
{
alert("The spouse must sign the questionnaire.");
}
else
{
save_document();
var str = "";
var elem = document.getElementById('dform').elements;
var q1 = $("input:radio[name='client_q1']:checked").val(); str += "&client_q1="+q1;
var q1a = $("input:radio[name='client_q1a']:checked").val(); str += "&client_q1a="+q1a;
var q2 = $("input:radio[name='client_q2']:checked").val(); str += "&client_q2="+q2;
var q3 = $("input:radio[name='client_q3']:checked").val(); str += "&client_q3="+q3;
var q4 = $("input:radio[name='client_q4']:checked").val(); str += "&client_q4="+q4;
var q4a = $("input:radio[name='client_q4a']:checked").val(); str += "&client_q4a="+q4a;
var q5 = $("input:radio[name='client_q5']:checked").val(); str += "&client_q5="+q5;
var q5a = $("input:radio[name='client_q6']:checked").val(); str += "&client_q6="+q5a;
var q5aa = $("input:radio[name='client_q6a']:checked").val(); str += "&client_q6a="+q5aa;
for(var i = 0; i < elem.length; i++)
{
if(elem[i].type != "radio")
{
str += "&"+elem[i].name;
str += "="+elem[i].value;
}
}
$('html,body').animate({
opacity: 0.8
}, 1000);
//alert(str);
$('.ui-save-block').fadeIn(500);
$('html.body.ui-save-block').css('opacity', '1');
$('.ui-save-block').find('h1').text("SENDING...");
$.ajax({
cache: false,
type: "POST",
data: str,
url: "../confidential_questionnaire_save_n_send.php",
success: function(msg)
{
//window.location = "confidential_questionnaire.php";
$("#questionnaire").html(msg);
$('html,body').animate({
scrollTop: 0
}, 1000, function(){
$("#questionnaire").hide().fadeIn(800);
$('html,body').animate({
opacity: 1
}, 1000);
$('.ui-save-block').fadeOut(500);
});
}
});
}
}
else
{
save_document();
var str = "";
var elem = document.getElementById('dform').elements;
var q1 = $("input:radio[name='client_q1']:checked").val(); str += "&client_q1="+q1;
var q1a = $("input:radio[name='client_q1a']:checked").val(); str += "&client_q1a="+q1a;
var q2 = $("input:radio[name='client_q2']:checked").val(); str += "&client_q2="+q2;
var q3 = $("input:radio[name='client_q3']:checked").val(); str += "&client_q3="+q3;
var q4 = $("input:radio[name='client_q4']:checked").val(); str += "&client_q4="+q4;
var q4a = $("input:radio[name='client_q4a']:checked").val(); str += "&client_q4a="+q4a;
var q5 = $("input:radio[name='client_q5']:checked").val(); str += "&client_q5="+q5;
var q5a = $("input:radio[name='client_q6']:checked").val(); str += "&client_q6="+q5a;
var q5aa = $("input:radio[name='client_q6a']:checked").val(); str += "&client_q6a="+q5aa;
for(var i = 0; i < elem.length; i++)
{
if(elem[i].type != "radio")
{
str += "&"+elem[i].name;
str += "="+elem[i].value;
}
}
$('html,body').animate({
opacity: 0.8
}, 1000);
//alert(str);
$('.ui-save-block').fadeIn(500);
$('html.body.ui-save-block').css('opacity', '1');
$('.ui-save-block').find('h1').text("SENDING...");
$.ajax({
cache: false,
type: "POST",
data: str,
url: "../confidential_questionnaire_save_n_send.php",
success: function(msg)
{
//window.location = "confidential_questionnaire.php";
$("#questionnaire").html(msg);
$('html,body').animate({
scrollTop: 0
}, 1000, function(){
$("#questionnaire").hide().fadeIn(800);
$('html,body').animate({
opacity: 1
}, 1000);
$('.ui-save-block').fadeOut(500);
});
}
});
}
}
}
function clearborder()
{
document.getElementById('applicant').className='border_white';
document.getElementById('assets').className='border_white';
document.getElementById('calculate').className='border_white';
document.getElementById('signature').className='border_white';
}
function redborder(id)
{
clearborder();
document.getElementById(id).className='border_error';
}
$(document).ready(function(e) {
calc_networth();
calc_insurance();
});
function check_field(name)
{
var output = "";;
output = $('#id-'+name).val();
var s_name = name;
if(s_name.indexOf("phone") != -1)
{
output = output.replace("-", "");
output = output.replace("(", "");
output = output.replace(")", "");
output = output.replace(".", "");
output = output.replace("+", "");
output = output.replace("*", "");
}
if(output != ''){$('#id-'+name).removeClass('empty-data'); }
else{ $('#id-'+name).addClass('empty-data'); }
return output;
}
function success_result()
{
//alert("Saved");
}
function failed_result()
{
//alert("Failed");
}
function save_personal_info()
{
var str = "dummy=dummy";
var cfn = check_field('client-first-name-'); str += "&cfn="+cfn;
var cmn = $('#id-client-middle-name-').val(); str += "&cmn="+cmn;
var cln = check_field('client-last-name-'); str += "&cln="+cln;
var cocc = check_field('client-occupation-'); str += "&cocc="+cocc;
var cby = check_field('client-birth-year-'); str += "&cby="+cby;
var sfn = $('#id-spouse-first-name-').val(); str += "&sfn="+sfn;
var smn = $('#id-spouse-middle-name-').val(); str += "&smn="+smn;
var sln = $('#id-spouse-last-name-').val(); str += "&sln="+sln;
var socc = $('#id-spouse-occupation-').val(); str += "&socc="+socc;
var sby = $('#id-spouse-birth-year-').val(); str += "&sby="+sby;
var smdn = $('#id-spouse-maiden-name-').val(); str += "&smdn="+smdn;
var ipm = $('#id-prior-marraige').val(); str += "&ipm="+ipm;
var ipmhm = $('#id-spouse-how-many-').val(); str += "&ipmhm="+ipmhm;
var cpp = check_field('client-primary-phone-'); str += "&cpp="+cpp;
var cmp = $('#id-client-mobile-phone-').val(); str += "&cmp="+cmp;
var cop = $('#id-client-office-phone-').val(); str += "&cop="+cop;
var cfxn = $('#id-client-fax-number-').val(); str += "&cfxn="+cfxn;
var csa = check_field('client-street-address-'); str += "&csa="+csa;
var cct = check_field('client-city-'); str += "&cct="+cct;
var ccy = $('#id-client-county-').val(); str += "&ccy="+ccy;
var ccs = check_field('client-state-'); str += "&ccs="+ccs;
var ccz = check_field('client-zip-'); str += "&ccz="+ccz;
var cce = check_field('client-email-'); str += "&cce="+cce;
var adt = $('#id-additional-details').val(); str += "&adt="+adt;
var cys = check_field('client-your-signature-'); str += "&cys="+cys;
var css = check_field('client-spouse-signature-'); str += "&css="+css;
$.ajax
({
cache: false,
type: "POST",
dataType: "json",
data: str,
url: "binx/ajax/update-personal-user-info.php",
success: function(msg)
{
//alert(msg.message);
if(msg.message == "Success")
{
success_result();
}
else
{
failed_result();
}
},error: function()
{
alert('Error save_personal_info');
}
});
}
function save_asset_questions()
{
var str = "username="+$('#id-client-email-').val();
var q1 = $("input:radio[name='client_q1']:checked").val(); str += "&q1="+q1;
var q1a = $("input:radio[name='client_q1a']:checked").val(); str += "&q1a="+q1a;
var q2 = $("input:radio[name='client_q2']:checked").val(); str += "&q2="+q2;
var q2_explain = $("#id-client-please-explain-q2--").val(); str += "&q2_explain="+q2_explain;
var q3 = $("input:radio[name='client_q3']:checked").val(); str += "&q3="+q3;
var q3_explain = $("#id-client-please-explain-q3--").val(); str += "&q3_explain="+q3_explain;
var q4 = $("input:radio[name='client_q4']:checked").val(); str += "&q4="+q4;
var q4a = $("input:radio[name='client_q4a']:checked").val(); str += "&q4a="+q4a;
var q4_explain = $("#id-client-please-explain-q4--").val(); str += "&q4_explain="+q4_explain;
var q5 = $("input:radio[name='client_q5']:checked").val(); str += "&q5="+q5;
var q5_explain = $("#id-client-please-explain-q5--").val(); str += "&q5_explain="+q5_explain;
var q5a = $("input:radio[name='client_q6']:checked").val(); str += "&q5a="+q5a;
var q5aa = $("input:radio[name='client_q6a']:checked").val(); str += "&q5aa="+q5aa;
var q5aa_explain = $("#id-client-please-explain-q6a--").val(); str += "&q5aa_explain="+q5aa_explain;
var q5aa_when = $("#id-client-please-explain-q6b--").val(); str += "&q5aa_when="+q5aa_when;
var q6a = $("#id-client-0-1").val(); str += "&q6a="+q6a;
var q6b = $("#id-client-0-2").val(); str += "&q6b="+q6b;
var q6c = $("#id-client-0-3").val(); str += "&q6c="+q6c;
var q6d = $("#id-client-0-4").val(); str += "&q6d="+q6d;
var q6e = $("#id-client-0-5").val(); str += "&q6e="+q6e;
var q6f = $("#id-client-0-6").val(); str += "&q6f="+q6f;
var q6g = $("#id-client-0-7").val(); str += "&q6g="+q6g;
var q6h = $("#id-client-0-8").val(); str += "&q6h="+q6h;
$.ajax
({
cache: false,
type: "POST",
dataType: "json",
data: str,
url: "binx/ajax/update-asset-question.php",
success: function(msg)
{
//alert(msg.message);
if(msg.message == "Success")
{
success_result();
}
else
{
failed_result();
}
},error: function()
{
alert('Error save_asset_questions');
}
});
}
function save_children()
{
var str = "username="+$('#id-client-email-').val();
for(var i = 1; i < 6; i++)
{
var bfn = $('#id-beneficiary-name-'+i).val(); str += "&bfn"+i+"="+bfn;
var brl = $('#id-beneficiary-relationship-'+i).val(); str += "&brl"+i+"="+brl;
var bot = $('#id-beneficiary-other-'+i).val(); str += "&bot"+i+"="+bot;
var bag = $('#id-beneficiary-age-'+i).val(); str += "&bag"+i+"="+bag;
var bcm = $('#id-beneficiary-comments-'+i).val(); str += "&bcm"+i+"="+bcm;
}
$.ajax
({
cache: false,
type: "POST",
dataType: "json",
data: str,
url: "binx/ajax/update-blueprint-beneficiary.php",
success: function(msg)
{
//alert(msg.message);
if(msg.message == "Success")
{
success_result();
}
else
{
failed_result();
}
},error: function()
{
alert('Error save_children');
}
});
}
function save_blueprint_assets()
{
var str = "username="+$('#id-client-email-').val();
for(var i = 1; i < 19; i++)
{
var can = $('#id-client-asset-value--'+i).closest('tr').find('td:first').find('p').text();
can = can.replace(":", "");
str += "&can"+i+"="+can;
var cav = $('#id-client-asset-value--'+i).val(); str += "&cav"+i+"="+cav;
var cat = $('#id-client-asset-title--'+i).val(); str += "&cat"+i+"="+cat;
}
$.ajax
({
cache: false,
type: "POST",
dataType: "json",
data: str,
url: "binx/ajax/update-blueprint-assets.php",
success: function(msg)
{
//alert(msg.message);
if(msg.message == "Success")
{
success_result();
}
else
{
failed_result();
}
},error: function()
{
alert('Error save_blueprint_assets');
}
});
}
function save_blueprint_liabilities()
{
var str = "username="+$('#id-client-email-').val();
for(var i = 1; i < 10; i++)
{
var cln = $('#id-client-liabilities-value--'+i).closest('tr').find('td:first').find('p').text();
cln = cln.replace(":", "");
str += "&cln"+i+"="+cln;
var clv = $('#id-client-liabilities-value--'+i).val(); str += "&clv"+i+"="+clv;
}
$.ajax
({
cache: false,
type: "POST",
dataType: "json",
data: str,
url: "binx/ajax/update-blueprint-liabilities.php",
success: function(msg)
{
//alert(msg.message);
if(msg.message == "Success")
{
success_result();
}
else
{
failed_result();
}
},error: function()
{
alert('Error save_blueprint_liabilities');
}
});
}
function save_document()
{
save_blueprint_liabilities();
save_blueprint_assets();
save_personal_info();
save_children();
save_asset_questions();
}
function save_user_document()
{
$('html,body').animate({
opacity: 0.8
}, 1000);
//alert(str);
$('.ui-save-block').fadeIn(500);
$('html.body.ui-save-block').css('opacity', '0.5');
$('.ui-save-block').find('h1').text("SAVING...");
save_blueprint_liabilities();
save_blueprint_assets();
save_personal_info();
save_children();
save_asset_questions();
$('html,body').animate({
opacity: 1
}, 1000);
$('.ui-save-block').fadeOut(500);
}
-->
</script>
<style type="text/css">
.ui-form-element{
margin-bottom:3px;
}
.ui-questionnaire-section-form{
background-color:#FFF;
border:1px solid #bca6a0;
padding:8px;
margin-bottom:8px;
}
.ui-questionnaire-section-subform{
background:#f3f1e8;
border:1px solid #f2e5e2;
padding:8px;
margin-bottom:8px;
}
.content{
margin-left:16px;
}
.content_, div, h1, h2, h3{
font-family:"Trajan", Times, serif;
font-weight:normal;
color:#410900;
}
.empty-data{
border:1px solid #a69c97 !important;
box-shadow: 0px 2px 5px rgba(0, 0, 0, 0.10);
-moz-box-shadow: 0px 2px 5px rgba(0, 0, 0, 0.10);
-webkit-box-shadow: 0px 2px 5px rgba(0, 0, 0, 0.10);
}
p{
font-size:16px !important;
font-family:"Times New Roman", Times, serif;
}
input, select{
background-color:#FFF;
padding:2px;
border:1px solid #b7ada8 !important;
}
.ui-radio{
margin-right:-1px;
cursor:pointer;
}
td{
vertical-align:top;
}
#id-tub-selects p{
position:relative;
top:-14px;
margin-bottom:-14px;
}
th{
font-family:"Trajan", Times, serif;
font-weight:normal;
color:#410900;
border:1px solid #b7ada8 !important;
background: rgb(243,241,232); /* Old browsers */
background: -moz-linear-gradient(top, rgba(243,241,232,1) 0%, rgba(231,228,214,1) 100%); /* FF3.6+ */
background: -webkit-gradient(linear, left top, left bottom, color-stop(0%,rgba(243,241,232,1)), color-stop(100%,rgba(231,228,214,1))); /* Chrome,Safari4+ */
background: -webkit-linear-gradient(top, rgba(243,241,232,1) 0%,rgba(231,228,214,1) 100%); /* Chrome10+,Safari5.1+ */
background: -o-linear-gradient(top, rgba(243,241,232,1) 0%,rgba(231,228,214,1) 100%); /* Opera 11.10+ */
background: -ms-linear-gradient(top, rgba(243,241,232,1) 0%,rgba(231,228,214,1) 100%); /* IE10+ */
background: linear-gradient(to bottom, rgba(243,241,232,1) 0%,rgba(231,228,214,1) 100%); /* W3C */
filter: progid:DXImageTransform.Microsoft.gradient( startColorstr='#f3f1e8', endColorstr='#e7e4d6',GradientType=0 ); /* IE6-9 */
padding:6px 12px 6px 12px;
margin-right:-1px;
}
#questionnaire{
padding:24px;
border:1px solid #000;
display:inline-block;
background-image:url(../images/questionnaire_feedback_bg.jpg);
color:#ffffff !important;
text-shadow:1px 1px 2px #0c2872;
box-shadow:inset 0px 6px 8px rgba(0, 0, 0, 0.32);
-moz-box-shadow:inset 0px 6px 8px rgba(0, 0, 0, 0.32);
-webkit-box-shadow:inset 0px 6px 8px rgba(0, 0, 0, 0.32);
}
#questionnaire a{
color:#ffffff !important;
text-shadow:-1px 1px 2px #0c2872;
}
.ui-save-block{
position:fixed;
width:100%;
height:100%;
top:0px;
left:0px;
z-index:100001;
display:none;
text-align:center;
vertical-align:middle;
padding:250px;
color:#410900 !important;
font-size:24px;
text-shadow:-1px 1px 12px #ffffff;
opacity:1;
font-family:"Trebuchet MS", Arial, Helvetica, sans-serif;
}
</style>
<div class="ui-save-block"><h1 style="color:#410900 !important; z-index:100003; font-family:Trebuchet MS, Arial, Helvetica, sans-serif; ">SENDING...</h1></div>
<div class="content" style="font-size:12px !important;">
<div class="content_" style="margin:10px; position:relative; left:10px;">
<center>
<div id="questionnaire" style="display:none;">
</div>
</center>
<form name="dform" id="dform" method="post" action="confidential_questionnaire.php" accept-charset="UTF-8">
<center>
<div align="left" style="margin-top:8px; width:818px; font-size:12px;">
<p>
This is the questionnaire the attorney needs to begin the process of creating your customized asset protection blueprint. Your information will be kept confidential and is protected by attorney client privilege. Your blueprint will be completed by one of the finest and most experienced asset protection attorneys in the country. The blueprint will clearly illustrate the legal entities you need to best protect your assets and is customized and tailored based on your profession, assets, goals, and the state in which you live.
</p>
</div>
</center>
<center>
<div align="left" style="width:600px;">
<?php print $output;?>
</div>
</center>
<br />
<div class="ui-questionnaire-section-form">
<div class="ui-questionnaire-header-title" style="width:100%; text-align:center; vertical-align:top;">
<h1 style="font-size:16px;">
Personal Information
</h1>
<hr style="width:80%;" />
</div>
<br />
<div class="ui-questionnaire-section-subform">
<h3 style="font-size:14px;">
Yourself
</h3>
<hr />
<?= element_input("client", "first-name", "", "medium", 64, $PIR['first_name'], 0, 1) ?>
<?= element_input("client", "middle-name", "", "medium", 64, $PIR['middle_name'], 0, 0) ?>
<?= element_input("client", "last-name", "", "medium", 64, $PIR['last_name'], 0, 1) ?>
<?= element_input("client", "occupation", "", "large", 128, $PIR['occupation'], 0, 1) ?>
<div class="ui-form-element" style="display:inline-block;">
<label class="ui-label">
Year of Birth
<br />
<?= element_select_array("client", "birth-year", "", "medium", 0, $PIR['birth_year'], $YEAR_ARR, 0) ?>
</label>
</div>
</div>
<div style="clear:both"></div>
<div class="ui-questionnaire-section-subform">
<h3 style="font-size:14px;">
Your Spouse
</h3>
<hr />
<?= element_input("spouse", "first-name", "", "medium", 64, $PIR['spouse_first_name'], 0, 1) ?>
<?= element_input("spouse", "middle-name", "", "medium", 64, $PIR['spouse_middle_name'], 0, 0) ?>
<?= element_input("spouse", "last-name", "", "medium", 64, $PIR['spouse_last_name'], 0, 1) ?>
<?= element_input("spouse", "occupation", "", "large", 128, $PIR['spouse_occupation'], 0, 1) ?>
<div class="ui-form-element" style="display:inline-block;">
<label class="ui-label">
Year of Birth
<br />
<?= element_select_array("spouse", "birth-year", "", "medium", 0, $PIR['spouse_birth_year'], $YEAR_ARR, 0) ?>
</label>
</div>
</div>
<div style="clear:both"></div>
<div style="padding:8px;">
<?= element_input("spouse", "maiden-name", "", "medium", 64, $PIR['maiden_name'], 0, 1) ?>
<div class="ui-form-element" style="display:inline-block;">
<label class="ui-label">
Any Prior Marriages?
<br />
<script language="javascript">
function toggle_prior_marriages()
{
var temp = $('#id-prior-marriage').val();
if( temp == "yes" )
{
$('#id-prior-marriage-how-many').fadeIn(200);
}
else
{
$('#id-prior-marriage-how-many').fadeOut(200);
}
}
</script>
<?php $TPM_PM = $PIR['prior_marraige']; ?>
<select class="ui-select" id="id-prior-marriage" name="prior_marraige" onchange="toggle_prior_marriages()" style="width:100px;">
<option value="x" >Select</option>
<option value="yes" >Yes</option>
<option value="no" >No</option>
</select>
</label>
</div>
<div style="display:inline-block;">
<div id="id-prior-marriage-how-many" style="display:none;">
<?= element_input("spouse", "how-many", "", "small", 4, $PIR['prior_marraige_num'], 1, 0) ?>
</div>
</div>
<div style="clear:both"></div>
<br />
<br />
<div style="clear:both"></div>
<?= element_input("client", "primary-phone", "", "medium", 10, preg_replace("/[^A-Za-z0-9]/","",$PIR['evening_phone']), 1, 1) ?>
<?= element_input("client", "mobile-phone", "", "medium", 10, preg_replace("/[^A-Za-z0-9]/","",$PIR['mobile_phone']), 1, 0) ?>
<?= element_input("client", "office-phone", "", "medium", 10, preg_replace("/[^A-Za-z0-9]/","",$PIR['office_phone']), 1, 0) ?>
<?= element_input("client", "fax-number", "", "medium", 10, preg_replace("/[^A-Za-z0-9]/","",$PIR['fax_number']), 1, 0) ?>
<div style="clear:both"></div>
<br />
<div style="clear:both"></div>
<?= element_input("client", "street-address", "", "large", 128, $PIR['street_address'], 0, 1) ?>
<?= element_input("client", "city", "", "medium", 128, $PIR['city'], 0, 1) ?>
<?= element_input("client", "county", "", "medium", 128, $PIR['county'], 0, 0) ?>
<?= element_select_array("client", "state", "", "medium", 0, $PIR['state'], $STATE_ARR, 1) ?>
<?= element_input("client", "zip", "", "small", 5, $PIR['zip'], 1, 1) ?>
<div style="clear:both"></div>
<?= element_input("client", "email", "", "large", 128, $PIR['email'], 0, 1) ?>
</div>
<div style="clear:both"></div>
<br />
</div>
<div class="ui-questionnaire-section-form">
<div class="ui-questionnaire-header-title" style="width:100%; text-align:center; vertical-align:top;">
<h1 style="font-size:16px;">
Children / Beneficiaries
</h1>
<hr style="width:80%;" />
</div>
<br />
<div class="ui-questionnaire-section-subform">
<?php
$MY_BEN_QRY = $db->query("SELECT fullname, relationship, relationship_other, age, comments FROM BlueprintBeneficiaries WHERE username = '$USERNAME' AND bene_id = '1' AND username != ''");
$BEN = $MY_BEN_QRY[0];
?>
<?= element_inputx("beneficiary", "name", "1", "large", 128, $BEN['fullname'], 0, 0) ?>
<?= element_select_arrayx("beneficiary", "relationship", "1", "medium", 0, $BEN['relationship'], $RELATION_ARR, 0) ?>
<?= element_inputx("beneficiary", "other", "1", "small", 64, $BEN['relationship_other'], 0, 0) ?>
<?= element_inputx("beneficiary", "age", "1", "small", 64, $BEN['age'], 0, 0) ?>
<?= element_inputx("beneficiary", "comments", "1", "large", 128, $BEN['comments'], 0, 0) ?>
<?php
$MY_BEN_QRY = $db->query("SELECT fullname, relationship, relationship_other, age, comments FROM BlueprintBeneficiaries WHERE username = '$USERNAME' AND bene_id = '2' AND username != ''");
$BEN = $MY_BEN_QRY[0];
?>
<?= element_inputx("beneficiary", "name", "2", "large", 128, $BEN['fullname'], 0, 0) ?>
<?= element_select_arrayx("beneficiary", "relationship", "2", "medium", 0, $BEN['relationship'], $RELATION_ARR, 0) ?>
<?= element_inputx("beneficiary", "other", "2", "small", 64, $BEN['relationship_other'], 0, 0) ?>
<?= element_inputx("beneficiary", "age", "2", "small", 64, $BEN['age'], 0, 0) ?>
<?= element_inputx("beneficiary", "comments", "2", "large", 128, $BEN['comments'], 0, 0) ?>
<?php
$MY_BEN_QRY = $db->query("SELECT fullname, relationship, relationship_other, age, comments FROM BlueprintBeneficiaries WHERE username = '$USERNAME' AND bene_id = '3' AND username != ''");
$BEN = $MY_BEN_QRY[0];
?>
<?= element_inputx("beneficiary", "name", "3", "large", 128, $BEN['fullname'], 0, 0) ?>
<?= element_select_arrayx("beneficiary", "relationship", "3", "medium", 0, $BEN['relationship'], $RELATION_ARR, 0) ?>
<?= element_inputx("beneficiary", "other", "3", "small", 64, $BEN['relationship_other'], 0, 0) ?>
<?= element_inputx("beneficiary", "age", "3", "small", 64, $BEN['age'], 0, 0) ?>
<?= element_inputx("beneficiary", "comments", "3", "large", 128, $BEN['comments'], 0, 0) ?>
<?php
$MY_BEN_QRY = $db->query("SELECT fullname, relationship, relationship_other, age, comments FROM BlueprintBeneficiaries WHERE username = '$USERNAME' AND bene_id = '4' AND username != ''");
$BEN = $MY_BEN_QRY[0];
?>
<?= element_inputx("beneficiary", "name", "4", "large", 128, $BEN['fullname'], 0, 0) ?>
<?= element_select_arrayx("beneficiary", "relationship", "4", "medium", 0, $BEN['relationship'], $RELATION_ARR, 0) ?>
<?= element_inputx("beneficiary", "other", "4", "small", 64, $BEN['relationship_other'], 0, 0) ?>
<?= element_inputx("beneficiary", "age", "4", "small", 64, $BEN['age'], 0, 0) ?>
<?= element_inputx("beneficiary", "comments", "4", "large", 128, $BEN['comments'], 0, 0) ?>
<?php
$MY_BEN_QRY = $db->query("SELECT fullname, relationship, relationship_other, age, comments FROM BlueprintBeneficiaries WHERE username = '$USERNAME' AND bene_id = '5' AND username != ''");
$BEN = $MY_BEN_QRY[0];
?>
<?= element_inputx("beneficiary", "name", "5", "large", 128, $BEN['fullname'], 0, 0) ?>
<?= element_select_arrayx("beneficiary", "relationship", "5", "medium", 0, $BEN['relationship'], $RELATION_ARR, 0) ?>
<?= element_inputx("beneficiary", "other", "5", "small", 64, $BEN['relationship_other'], 0, 0) ?>
<?= element_inputx("beneficiary", "age", "5", "small", 64, $BEN['age'], 0, 0) ?>
<?= element_inputx("beneficiary", "comments", "5", "large", 128, $BEN['comments'], 0, 0) ?>
<?php
$MY_BEN_QRY = $db->query("SELECT fullname, relationship, relationship_other, age, comments FROM BlueprintBeneficiaries WHERE username = '$USERNAME' AND bene_id = '6' AND username != ''");
$BEN = $MY_BEN_QRY[0];
?>
<?= element_inputx("beneficiary", "name", "6", "large", 128, $BEN['fullname'], 0, 0) ?>
<?= element_select_arrayx("beneficiary", "relationship", "6", "medium", 0, $BEN['relationship'], $RELATION_ARR, 0) ?>
<?= element_inputx("beneficiary", "other", "6", "small", 64, $BEN['relationship_other'], 0, 0) ?>
<?= element_inputx("beneficiary", "age", "6", "small", 64, $BEN['age'], 0, 0) ?>
<?= element_inputx("beneficiary", "comments", "6", "large", 128, $BEN['comments'], 0, 0) ?>
<div style="clear:both"></div>
</div>
<div style="clear:both"></div>
</div>
<div class="ui-questionnaire-section-form" style="font-size:12px;">
<div class="ui-questionnaire-header-title" style="width:100%; text-align:center; vertical-align:top;">
<h1 style="font-size:16px;">
Assets / Liabilities Section
</h1>
<hr style="width:80%;" />
</div>
<br />
<div class="ui-questionnaire-section-subform" style="padding-top:0px; padding-bottom:0px;">
<script language="javascript">
function toggle_q1()
{
var temp = $("input:radio[name='client_q1']:checked").val();
if( temp != 1 ){ $('#id-q1a').slideUp(300); $("input:radio[name='client_q1a']").prop('checked', false); }else{ $('#id-q1a').slideDown(300); }
}
</script>
<p style="display:inline-block">
1. Do you currently have a Revocable Living Trust?
</p>
<div class="ui-form-element" style="display:inline-block;">
<input class="ui-radio" type="radio" id="id-client-q1-y" name="client_q1" value="1" onchange="toggle_q1()" <?=( ($PIR['q1'] == "1") ? "checked='checked'" : "" )?> />
<label class="ui-radio ui-label" style="display:inline-block; position:relative; top:-1px; left:-3px;" for="id-client-q1-y" onclick="toggle_q1()" >
YES
</label>
</div>
<div class="ui-form-element" style="display:inline-block;">
<input class="ui-radio" type="radio" id="id-client-q1-n" name="client_q1" value="0" onchange="toggle_q1()"<?=( ($PIR['q1'] == "0") ? "checked='checked'" : "" )?> />
<label class="ui-radio ui-label" style="display:inline-block; position:relative; top:-1px; left:-3px" for="id-client-q1-n" onclick="toggle_q1()">
NO
</label>
</div>
<!-- ---------------------------------------------------------------------- -->
<div class="ui-questionnaire-section-subform" id="id-q1a" style="display:<?=( ($PIR['q1'] == 1) ? "block" : "none" )?>; background-color:#f6f4ed;">
<p style="display:inline-block">
If Yes, does it require any changes?
</p>
<div class="ui-form-element" style="display:inline-block;">
<input class="ui-radio" type="radio" id="id-client-q1a-y" name="client_q1a" value="1" <?=( ($PIR['q1a'] == "1") ? "checked='checked'" : "" )?> />
<label class="ui-radio ui-label" style="display:inline-block; position:relative; top:-1px; left:-3px;" for="id-client-q1a-y">
YES
</label>
</div>
<div class="ui-form-element" style="display:inline-block;">
<input class="ui-radio" type="radio" id="id-client-q1a-n" name="client_q1a" value="0" <?=( ($PIR['q1a'] == "0") ? "checked='checked'" : "" )?> />
<label class="ui-radio ui-label" style="display:inline-block; position:relative; top:-1px; left:-3px" for="id-client-q1a-n">
NO
</label>
</div>
</div>
<!-- ---------------------------------------------------------------------- -->
</div>
<div class="ui-questionnaire-section-subform" style="padding-top:0px; padding-bottom:0px;">
<script language="javascript">
function toggle_q2()
{
var temp = $("input:radio[name='client_q2']:checked").val();
if( temp != 1 ){ $('#id-q2a').slideUp(300); $("#id-client-please-explain-q2--").val(""); }else{ $('#id-q2a').slideDown(300); }
}
</script>
<p style="display:inline-block">
2. Do you want some portion of your estate to be used for charitable purposes?
</p>
<div class="ui-form-element" style="display:inline-block;">
<input class="ui-radio" type="radio" id="id-client-q2-y" name="client_q2" value="1" onchange="toggle_q2()" <?=( ($PIR['q2'] == "1") ? "checked='checked'" : "" )?> />
<label class="ui-radio ui-label" style="display:inline-block; position:relative; top:-1px; left:-3px;" for="id-client-q2-y" onclick="toggle_q2()">
YES
</label>
</div>
<div class="ui-form-element" style="display:inline-block;">
<input class="ui-radio" type="radio" id="id-client-q2-n" name="client_q2" value="0" onchange="toggle_q2()" <?=( ($PIR['q2'] == "0") ? "checked='checked'" : "" )?> />
<label class="ui-radio ui-label" style="display:inline-block; position:relative; top:-1px; left:-3px" for="id-client-q2-n" onclick="toggle_q2()">
NO
</label>
</div>
<!-- ---------------------------------------------------------------------- -->
<div class="ui-questionnaire-section-subform" id="id-q2a" style="display:<?=( ($PIR['q2'] == 1) ? "block" : "none" )?>; background-color:#f6f4ed;">
<p style="display:inline-block">
Please explain:
</p>
<?= element_input("client-please-explain-q2", "", "", "xlarge", 128, $PIR['q2_explain'], 0, 0) ?>
</div>
</div>
<div class="ui-questionnaire-section-subform" style="padding-top:0px; padding-bottom:0px;">
<script language="javascript">
function toggle_q3()
{
var temp = $("input:radio[name='client_q3']:checked").val();
if( temp != 1 ){ $('#id-q3a').slideUp(300); $("#id-client-please-explain-q3--").val(""); }else{ $('#id-q3a').slideDown(300); }
}
</script>
<p style="display:inline-block">
3. Are you expecting an inheritance?
</p>
<div class="ui-form-element" style="display:inline-block;">
<input class="ui-radio" type="radio" id="id-client-q3-y" name="client_q3" value="1" onchange="toggle_q3()" <?=( ($PIR['q3'] == "1") ? "checked='checked'" : "" )?> />
<label class="ui-radio ui-label" style="display:inline-block; position:relative; top:-1px; left:-3px;" for="id-client-q3-y" onclick="toggle_q3()">
YES
</label>
</div>
<div class="ui-form-element" style="display:inline-block;">
<input class="ui-radio" type="radio" id="id-client-q3-n" name="client_q3" value="0" onchange="toggle_q3()" <?=( ($PIR['q3'] == "0") ? "checked='checked'" : "" )?> />
<label class="ui-radio ui-label" style="display:inline-block; position:relative; top:-1px; left:-3px" for="id-client-q3-n" onclick="toggle_q3()">
NO
</label>
</div>
<!-- ---------------------------------------------------------------------- -->
<div class="ui-questionnaire-section-subform" id="id-q3a" style="display:<?=( ($PIR['q3'] == 1) ? "block" : "none" )?>; background-color:#f6f4ed;">
<p style="display:inline-block">
Please explain:
</p>
<?= element_input("client-please-explain-q3", "", "", "xlarge", 128, $PIR['q3_explain'], 0, 0) ?>
</div>
</div>
<div class="ui-questionnaire-section-subform" style="padding-top:0px; padding-bottom:0px;">
<script language="javascript">
function toggle_q4()
{
var temp = $("input:radio[name='client_q4']:checked").val();
if( temp != 1 ){ $('#id-q4a').slideUp(300);
$("input:radio[name='client_q4a']").prop('checked', false);
$("#id-client-please-explain-q4--").val("");
}else{ $('#id-q4a').slideDown(300); }
}
function toggle_q4a()
{
var temp = $("input:radio[name='client_q4a']:checked").val();
if( temp != 1 ){ $('#id-q4aa').slideUp(300); $("#id-client-please-explain-q4--").val(""); }else{ $('#id-q4aa').slideDown(300); }
}
</script>
<p style="display:inline-block">
4. Have you ever been a defendant in a lawsuit?
</p>
<div class="ui-form-element" style="display:inline-block;">
<input class="ui-radio" type="radio" id="id-client-q4-y" name="client_q4" value="1" onchange="toggle_q4()" <?=( ($PIR['q4'] == "1") ? "checked='checked'" : "" )?> />
<label class="ui-radio ui-label" style="display:inline-block; position:relative; top:-1px; left:-3px;" for="id-client-q4-y" onclick="toggle_q4()">
YES
</label>
</div>
<div class="ui-form-element" style="display:inline-block;">
<input class="ui-radio" type="radio" id="id-client-q4-n" name="client_q4" value="0" onchange="toggle_q4()" <?=( ($PIR['q4'] == "0") ? "checked='checked'" : "" )?> />
<label class="ui-radio ui-label" style="display:inline-block; position:relative; top:-1px; left:-3px" for="id-client-q4-n" onclick="toggle_q4()">
NO
</label>
</div>
<div class="ui-questionnaire-section-subform" id="id-q4a" style="display:<?=( ($PIR['q4'] == 1) ? "block" : "none" )?>; background-color:#f6f4ed;">
<p style="display:inline-block">
Are you involved - directly or indirectly - in any current or potential litigation?
</p>
<div class="ui-form-element" style="display:inline-block;">
<input class="ui-radio" type="radio" id="id-client-q4a-y" name="client_q4a" value="1" onchange="toggle_q4a()" <?=( ($PIR['q4a'] == "1") ? "checked='checked'" : "" )?> />
<label class="ui-radio ui-label" style="display:inline-block; position:relative; top:-1px; left:-3px;" for="id-client-q4a-y" onclick="toggle_q4a()">
YES
</label>
</div>
<div class="ui-form-element" style="display:inline-block;">
<input class="ui-radio" type="radio" id="id-client-q4a-n" name="client_q4a" value="0" onchange="toggle_q4a()" <?=( ($PIR['q4'] == "0") ? "checked='checked'" : "" )?> />
<label class="ui-radio ui-label" style="display:inline-block; position:relative; top:-1px; left:-3px" for="id-client-q4a-n" onclick="toggle_q4a()">
NO
</label>
</div>
<!-- ---------------------------------------------------------------------- -->
<div class="ui-questionnaire-section-subform" id="id-q4aa" style="display:<?=( ($PIR['q4a'] == 1) ? "block" : "none" )?>; background-color:#faf9f5;">
<p style="display:inline-block">
Please explain:
</p>
<?= element_input("client-please-explain-q4", "", "", "xlarge", 128, $PIR['q4a_explain'], 0, 0) ?>
</div>
</div>
</div>
<div class="ui-questionnaire-section-subform" style="padding-top:0px; padding-bottom:0px;">
<script language="javascript">
function toggle_q5()
{
var temp = $("input:radio[name='client_q5']:checked").val();
if( temp != 0 ){ $('#id-q5a').slideUp(300); }else{ $('#id-q5a').slideDown(300); }
}
</script>
<p style="display:inline-block">
5. Are you a U.S. Citizen?
</p>
<div class="ui-form-element" style="display:inline-block;">
<input class="ui-radio" type="radio" id="id-client-q5-y" name="client_q5" value="1" onchange="toggle_q5()" <?=( ($PIR['q5'] == "1") ? "checked='checked'" : "" )?> />
<label class="ui-radio ui-label" style="display:inline-block; position:relative; top:-1px; left:-3px;" for="id-client-q5-y" onclick="toggle_q5()">
YES
</label>
</div>
<div class="ui-form-element" style="display:inline-block;">
<input class="ui-radio" type="radio" id="id-client-q5-n" name="client_q5" value="0" onchange="toggle_q5()" <?=( ($PIR['q5'] == "0") ? "checked='checked'" : "" )?> />
<label class="ui-radio ui-label" style="display:inline-block; position:relative; top:-1px; left:-3px" for="id-client-q5-n" onclick="toggle_q5()">
NO
</label>
</div>
<div class="ui-questionnaire-section-subform" id="id-q5a" style="display:<?=( ($PIR['q5'] == 0) ? "block" : "none" )?>; background-color:#f6f4ed;">
<p style="display:inline-block">
If not, please explain more about your citizenship:
</p>
<?= element_input("client-please-explain-q5", "", "", "xlarge", 128, $PIR['q5_explain'], 0, 0) ?>
</div>
</div>
<div class="ui-questionnaire-section-subform" style="padding-top:0px; padding-bottom:0px;">
<script language="javascript">
function toggle_q6()
{
var temp = $("input:radio[name='client_q6']:checked").val();
if( temp != 0 ){ $('#id-q6a').slideUp(300); }else{ $('#id-q6a').slideDown(300); }
}
function toggle_q6a()
{
var temp = $("input:radio[name='client_q6a']:checked").val();
if( temp != 1 ){ $('#id-q6ab').hide(); $('#id-q6aa').show(); }else{ $('#id-q6ab').show(); $('#id-q6aa').hide(); }
}
</script>
<p style="display:inline-block">
6. Is your spouse a U.S. citizen?
</p>
<div class="ui-form-element" style="display:inline-block;">
<input class="ui-radio" type="radio" id="id-client-q6-y" name="client_q6" value="1" onchange="toggle_q6()" <?=( ($PIR['q5a'] == "1") ? "checked='checked'" : "" )?> />
<label class="ui-radio ui-label" style="display:inline-block; position:relative; top:-1px; left:-3px;" for="id-client-q6-y" onclick="toggle_q6()">
YES
</label>
</div>
<div class="ui-form-element" style="display:inline-block;">
<input class="ui-radio" type="radio" id="id-client-q6-n" name="client_q6" value="0" onchange="toggle_q6()" <?=( ($PIR['q5a'] == "0") ? "checked='checked'" : "" )?> />
<label class="ui-radio ui-label" style="display:inline-block; position:relative; top:-1px; left:-3px" for="id-client-q6-n" onclick="toggle_q6()">
NO
</label>
</div>
<!-- ---------------------------------------------------------------------- -->
<div class="ui-questionnaire-section-subform" id="id-q6a" style="display:<?=( ($PIR['q5a'] == "0") ? "block" : "none" )?>; background-color:#f6f4ed;">
<p style="display:inline-block">
Does your spouse plan on becoming a U.S. citizen?
</p>
<div class="ui-form-element" style="display:inline-block;">
<input class="ui-radio" type="radio" id="id-client-q6a-y" name="client_q6a" value="1" onchange="toggle_q6a()" <?=( ($PIR['q5aa'] == "1") ? "checked='checked'" : "" )?> />
<label class="ui-radio ui-label" style="display:inline-block; position:relative; top:-1px; left:-3px;" for="id-client-q6a-y" onclick="toggle_q6a()">
YES
</label>
</div>
<div class="ui-form-element" style="display:inline-block;">
<input class="ui-radio" type="radio" id="id-client-q6a-n" name="client_q6a" value="0" onchange="toggle_q6a()" <?=( ($PIR['q5aa'] == "0") ? "checked='checked'" : "" )?> />
<label class="ui-radio ui-label" style="display:inline-block; position:relative; top:-1px; left:-3px" for="id-client-q6a-n" onclick="toggle_q6a()">
NO
</label>
</div>
<!-- ---------------------------------------------------------------------- -->
<div class="ui-questionnaire-section-subform" id="id-q6aa" style="display:<?=( ($PIR['q5aa'] == 0) ? "block" : "none" )?>; background-color:#faf9f5;">
<p style="display:inline-block">
If not, please explain:
</p>
<?= element_input("client-please-explain-q6a", "", "", "xlarge", 128, $PIR['q5aa_explain'], 0, 0) ?>
</div>
<!-- ---------------------------------------------------------------------- -->
<!-- ---------------------------------------------------------------------- -->
<div class="ui-questionnaire-section-subform" id="id-q6ab" style="display:<?=( ($PIR['q5aa'] == 1) ? "block" : "none" )?>; background-color:#faf9f5;">
<p style="display:inline-block">
If yes, when?
</p>
<?= element_input("client-please-explain-q6b", "", "", "xlarge", 128, $PIR['q5aa_when'], 0, 0) ?>
</div>
<!-- ---------------------------------------------------------------------- -->
</div>
<!-- ---------------------------------------------------------------------- -->
</div>
<?php
$RANK_ARR = array("1"=>"1", "2"=>"2", "3"=>"3", "4"=>"4", "5"=>"5", "6"=>"6", "7"=>"7", "8"=>"8");
?>
<div class="ui-questionnaire-section-subform" style="padding-top:0px; padding-bottom:0px;">
<p>
7. Please rank the importance to you of the following topics (1 being the most important, 8 the least):
</p>
<table border="0" cellpadding="0" id="id-tub-selects">
<tr>
<td>
<?= element_select_arrayx("client", "0", "1", "medium", 0, ( (!empty($PIR['q6a'])) ? ($PIR['q6a']*1) : "1" ), $RANK_ARR, 0) ?>
</td>
<td>
<p style="position:relative; top:-15px;">Asset Protection from lawsuits, claims, etc</p>
</td>
<td width="48px"> </td>
<td>
<?= element_select_arrayx("client", "0", "2", "medium", 0, ((!empty($PIR['q6b'])) ? $PIR['q6b'] : "0"), $RANK_ARR, 0) ?>
</td>
<td>
<p style="position:relative; top:-15px;">Charitable Planning</p>
</td>
</tr>
<tr>
<td>
<?= element_select_arrayx("client", "0", "3", "medium", 0, ((!empty($PIR['q6c'])) ? $PIR['q6c'] : "0"), $RANK_ARR, 0) ?>
</td>
<td>
<p style="position:relative; top:-15px;">Estate Planning</p>
</td>
<td width="48px"> </td>
<td>
<?= element_select_arrayx("client", "0", "4", "medium", 0, ((!empty($PIR['q6d'])) ? $PIR['q6d'] : "0"), $RANK_ARR, 0) ?>
</td>
<td>
<p style="position:relative; top:-15px;">Estate Taxes</p>
</td>
</tr>
<tr>
<td>
<?= element_select_arrayx("client", "0", "5", "medium", 0, ((!empty($PIR['q6e'])) ? $PIR['q6e'] : "0"), $RANK_ARR, 0) ?>
</td>
<td>
<p>Probate Avoidance</p>
</td>
<td width="48px"> </td>
<td>
<?= element_select_arrayx("client", "0", "6", "medium", 0, ((!empty($PIR['q6f'])) ? $PIR['q6f'] : "0"), $RANK_ARR, 0) ?>
</td>
<td>
<p>Income Taxes</p>
</td>
</tr>
<tr>
<td>
<?= element_select_arrayx("client", "0", "7", "medium", 0, ((!empty($PIR['q6g'])) ? $PIR['q6g'] : "0"), $RANK_ARR, 0) ?>
</td>
<td>
<p>Business Planning</p>
</td>
<td width="48px"> </td>
<td>
<?= element_select_arrayx("client", "0", "8", "medium", 0, ((!empty($PIR['q6h'])) ? $PIR['q6h'] : "0"), $RANK_ARR, 0) ?>
</td>
<td>
<p>
Other
<div style="position:relative; top:-37px; left:40px;">
<?= element_inputx("client", "", "asset-other", "medium", 128, $PIR['q6h_explain'], 0, 0) ?>
</div>
</p>
</td>
</tr>
</table>
</div>
<div class="ui-questionnaire-section-subform" style="padding-top:0px; padding-bottom:0px;">
<p>
8. List the values of all assets to be protected (estimate):
</p>
<div class="ui-questionnaire-section-subform" style="background-color:#faf9f5;">
<table border="0" cellpadding="0" id="id-tub-selects" width="100%">
<tr>
<td>
<table width="100%" border="0">
<tr>
<th width="175px">
Assets
</th>
<th width="108px">
Value in $(USD)
</th>
<th>
How Titled / Type of Entity
</th>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Cash:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, short_description FROM BlueprintAssets WHERE username = '$USERNAME' AND asset_id = '1' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-asset-value", "", "1", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;">
<?= element_inputx("client-asset-title", "", "1", "xlarge", 128, $MY_MMA['short_description'], 0, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Money Market Account:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, short_description FROM BlueprintAssets WHERE username = '$USERNAME' AND asset_id = '2' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-asset-value", "", "2", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;">
<?= element_inputx("client-asset-title", "", "2", "xlarge", 128, $MY_MMA['short_description'], 0, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Savings Accounts:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, short_description FROM BlueprintAssets WHERE username = '$USERNAME' AND asset_id = '3' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-asset-value", "", "3", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;">
<?= element_inputx("client-asset-title", "", "3", "xlarge", 128, $MY_MMA['short_description'], 0, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Stocks:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, short_description FROM BlueprintAssets WHERE username = '$USERNAME' AND asset_id = '4' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-asset-value", "", "4", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;">
<?= element_inputx("client-asset-title", "", "4", "xlarge", 128, $MY_MMA['short_description'], 0, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Mutal Funds:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, short_description FROM BlueprintAssets WHERE username = '$USERNAME' AND asset_id = '5' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-asset-value", "", "5", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;">
<?= element_inputx("client-asset-title", "", "5", "xlarge", 128, $MY_MMA['short_description'], 0, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Bonds:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, short_description FROM BlueprintAssets WHERE username = '$USERNAME' AND asset_id = '6' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-asset-value", "", "6", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;">
<?= element_inputx("client-asset-title", "", "6", "xlarge", 128, $MY_MMA['short_description'], 0, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Precious Metals:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, short_description FROM BlueprintAssets WHERE username = '$USERNAME' AND asset_id = '7' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-asset-value", "", "7", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;">
<?= element_inputx("client-asset-title", "", "7", "xlarge", 128, $MY_MMA['short_description'], 0, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Homes:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, short_description FROM BlueprintAssets WHERE username = '$USERNAME' AND asset_id = '8' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-asset-value", "", "8", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;">
<?= element_inputx("client-asset-title", "", "8", "xlarge", 128, $MY_MMA['short_description'], 0, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Investment Real Estate:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, short_description FROM BlueprintAssets WHERE username = '$USERNAME' AND asset_id = '9' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-asset-value", "", "9", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;">
<?= element_inputx("client-asset-title", "", "9", "xlarge", 128, $MY_MMA['short_description'], 0, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Investment Real Estate II:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, short_description FROM BlueprintAssets WHERE username = '$USERNAME' AND asset_id = '10' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-asset-value", "", "10", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;">
<?= element_inputx("client-asset-title", "", "10", "xlarge", 128, $MY_MMA['short_description'], 0, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Business interests:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, short_description FROM BlueprintAssets WHERE username = '$USERNAME' AND asset_id = '11' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-asset-value", "", "11", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;">
<?= element_inputx("client-asset-title", "", "11", "xlarge", 128, $MY_MMA['short_description'], 0, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Business interests II:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, short_description FROM BlueprintAssets WHERE username = '$USERNAME' AND asset_id = '12' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-asset-value", "", "12", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;">
<?= element_inputx("client-asset-title", "", "12", "xlarge", 128, $MY_MMA['short_description'], 0, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Automobiles:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, short_description FROM BlueprintAssets WHERE username = '$USERNAME' AND asset_id = '13' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-asset-value", "", "13", "medium", 16, (($MY_MMA['value'])?$MY_MMA['value']:""), 1, 0) ?>
</div>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;">
<?= element_inputx("client-asset-title", "", "13", "xlarge", 128, $MY_MMA['short_description'], 0, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Automobiles II:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, short_description FROM BlueprintAssets WHERE username = '$USERNAME' AND asset_id = '14' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-asset-value", "", "14", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;">
<?= element_inputx("client-asset-title", "", "14", "xlarge", 128, $MY_MMA['short_description'], 0, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>IRA Assets:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, short_description FROM BlueprintAssets WHERE username = '$USERNAME' AND asset_id = '15' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-asset-value", "", "15", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;">
<?= element_inputx("client-asset-title", "", "15", "xlarge", 128, $MY_MMA['short_description'], 0, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Other Retirement Assets:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, short_description FROM BlueprintAssets WHERE username = '$USERNAME' AND asset_id = '16' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-asset-value", "", "16", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;">
<?= element_inputx("client-asset-title", "", "16", "xlarge", 128, $MY_MMA['short_description'], 0, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Other Assets:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, short_description FROM BlueprintAssets WHERE username = '$USERNAME' AND asset_id = '17' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-asset-value", "", "17", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;">
<?= element_inputx("client-asset-title", "", "17", "xlarge", 128, $MY_MMA['short_description'], 0, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Other Assets II:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, short_description FROM BlueprintAssets WHERE username = '$USERNAME' AND asset_id = '18' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-asset-value", "", "18", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;">
<?= element_inputx("client-asset-title", "", "18", "xlarge", 128, $MY_MMA['short_description'], 0, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="border-top:1px solid #999; padding-left:128px; padding-top:12px;" colspan="3">
<p style="display:inline-block;">Total Assets:</p>
<div style="position:relative; top:-12px; margin-bottom:-12px; display:inline-block;">
$<?= element_input("client-asset-value", "", "total", "medium", 16, "", 1, 0) ?>
</div>
</td>
</tr>
</table>
<script language="javascript">
function calc_assets()
{
var elem_count = 19;
var temp_val = 0;
for( var i = 1; i < elem_count; i++ )
{
var tv = $('#id-client-asset-value--'+i).val() + "";
if( tv == null || tv == "" || tv == "undefined")
{
temp_val += 0;
}
else
{
temp_val += parseInt(tv);
}
}
$('#id-client-asset-value--total').val(temp_val);
calc_networth();
}
function calc_liabilities()
{
var elem_count = 7;
var temp_val = 0;
for( var i = 1; i < elem_count; i++ )
{
var tv = $('#id-client-liabilities-value--'+i).val() + "";
if( tv == null || tv == "" || tv == "undefined")
{
temp_val += 0;
}
else
{
temp_val += parseInt(tv);
}
}
$('#id-client-liabilities-value--total').val(temp_val);
calc_networth();
}
function calc_insurance()
{
var xv = $('#id-client-liabilities-value--7').val();
var yv = $('#id-client-liabilities-value--8').val();
var zv = $('#id-client-liabilities-value--9').val();
var temp_val = 0;
temp_val = (xv*1)+(yv*1)+(zv*1);
$('#id-client-insurance-value--total').val(temp_val);
}
function calc_networth()
{
var aelem_count = 19;
var atemp_val = 0;
for( var ai = 1; ai < aelem_count; ai++ )
{
var atv = $('#id-client-asset-value--'+ai).val() + "";
if( atv == null || atv == "" || atv == "undefined")
{
atemp_val += 0;
}
else
{
atemp_val += parseInt(atv);
}
}
var lelem_count = 7;
var ltemp_val = 0;
for( var li = 1; li < lelem_count; li++ )
{
var ltv = $('#id-client-liabilities-value--'+li).val() + "";
if( ltv == null || ltv == "" || ltv == "undefined")
{
ltemp_val += 0;
}
else
{
ltemp_val += parseInt(ltv);
}
}
var temp_total = ( atemp_val - ltemp_val ) + "";
var total_num = temp_total.replace(/(\s)/g, '');
temp_total = total_num.replace(/(\d)(?=(\d{3})+(?!\d))/g, "$1,");
$('#id-net-worth').html("$"+temp_total+".00");
$('#id-client-liabilities-value--total').val(ltemp_val);
$('#id-client-asset-value--total').val(atemp_val);
}
</script>
<hr />
</td>
</tr>
<tr>
<td valign="top" style="vertical-align:top;">
<div class="ui-questionnaire-section-subform" style="background-color:#fcfbf9; display:inline-block; width:47%;">
<table width="100%" border="0">
<tr>
<th width="150px">
Liabilities
</th>
<th width="100px">
Value in $(USD)
</th>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Home Mortgages:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, liability_name FROM BlueprintLiabilities WHERE username = '$USERNAME' AND liability_id = '1' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-liabilities-value", "", "1", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Other R/F Mortgages:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, liability_name FROM BlueprintLiabilities WHERE username = '$USERNAME' AND liability_id = '2' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-liabilities-value", "", "2", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Other:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, liability_name FROM BlueprintLiabilities WHERE username = '$USERNAME' AND liability_id = '3' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-liabilities-value", "", "3", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Other:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, liability_name FROM BlueprintLiabilities WHERE username = '$USERNAME' AND liability_id = '4' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-liabilities-value", "", "4", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Other:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, liability_name FROM BlueprintLiabilities WHERE username = '$USERNAME' AND liability_id = '5' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-liabilities-value", "", "5", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Other:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_assets();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, liability_name FROM BlueprintLiabilities WHERE username = '$USERNAME' AND liability_id = '6' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-liabilities-value", "", "6", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="border-top:1px solid #999; padding-left:104px; padding-top:12px;" colspan="2">
<p style="display:inline-block;">Total Liabilities:</p>
<div style="position:relative; top:-12px; margin-bottom:-12px; display:inline-block;">
$<?= element_input("client-liabilities-value", "", "total", "medium", 16, "", 1, 0) ?>
</div>
</td>
</tr>
</table>
</div>
<div class="ui-questionnaire-section-subform" style="background-color:#fcfbf9; display:inline-block; width:48%; position:relative; top:-53px;">
<table width="100%" border="0">
<tr>
<th width="150px">
Insurance
</th>
<th width="100px">
Value in $(USD)
</th>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Insurance on You:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_insurance();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, liability_name FROM BlueprintLiabilities WHERE username = '$USERNAME' AND liability_id = '7' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-liabilities-value", "", "7", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Insurance on Spouse:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_insurance();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, liability_name FROM BlueprintLiabilities WHERE username = '$USERNAME' AND liability_id = '8' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-liabilities-value", "", "8", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="padding-left:16px;">
<p>Last Survivor Insurance:</p>
</td>
<td>
<div style="position:relative; top:-12px; margin-bottom:-12px;" onkeyup="calc_insurance();">
<?php
$MY_MMA_QRY = $db->query("SELECT value, liability_name FROM BlueprintLiabilities WHERE username = '$USERNAME' AND liability_id = '9' AND username != ''");
$MY_MMA = $MY_MMA_QRY[0];
?>
$<?= element_inputx("client-liabilities-value", "", "9", "medium", 16, $MY_MMA['value'], 1, 0) ?>
</div>
</td>
</tr>
<tr>
<td style="border-top:1px solid #999; padding-left:104px; padding-top:12px;" colspan="2">
<p style="display:inline-block;">Total Insurance:</p>
<div style="position:relative; top:-12px; margin-bottom:-12px; display:inline-block;">
$<?= element_input("client-insurance-value", "", "total", "medium", 16, "", 1, 0) ?>
</div>
</td>
</tr>
</table>
</div>
<div class="ui-questionnaire-section-subform"
style="vertical-align:middle; background-color:#F3F1E8; display:inline-block; width:48%; position:relative;">
<center>
YOUR NET WORTH:
<h1>
<strong>
<div id="id-net-worth" style="display:inline-block; font-weight:bold; font-size:22px;">
$0.00
</div>
</strong>
<div style="display:inline-block; position:relative; left:32px;">
</div>
</h1>
</center>
</div>
</td>
</tr>
</table>
</div>
</div>
</div>
<!-- ================================================================================================================
================================================================================================================= -->
<div class="ui-questionnaire-section-form">
<div class="ui-questionnaire-header-title" style="width:100%; text-align:center; vertical-align:top;">
<h1 style="font-size:16px;">
Additional Details, Goals, and Concerns
</h1>
<hr style="width:80%;" />
</div>
<br />
<center>
<div class="ui-questionnaire-section-subform" style="padding-top:0px; padding-bottom:0px;">
<textarea id="id-additional-details" name="additional" style="width:740px; margin:5px 20px" rows="7"><?=$PIR['additional_details']?></textarea>
<p align="justify" style="width:94%;">
We certify that to the best of our knowledge, the forgoing is true, correct, and complete. You may rely on this information in providing advice and preparing documents for our estate and business plans. By my/our signature(s) below. I/We hereby provide Attorneys with our informed consent to share my/our information with representatives from American Society for Asset Protection, and acknowledge that I/we understand that this consent represents a waiver of any Attorney/Client privilege otherwise available. By signing below you authorize us to deal with your other advisors, and your other advisors to so deal with us.
</p>
<hr />
<div align="left">
<label class="ui-label">Date:<br />
<h3 style="float:left; position:relative; left:5px; font-size:16px;"><?php echo date('l jS \of F Y');?></h3>
</label>
<div style="float:right">
<?= element_input("client", "your-signature", "", "large", 100, $PIR['signature_1'], 0, 1) ?>
<div style="clear:both"></div>
<?= element_input("client", "spouse-signature", "", "large", 100, $PIR['signature_2'], 0, 1) ?>
</div>
<br />
<div style="clear:both"></div>
<br />
</div>
</div>
</center>
</div>
<br />
<hr />
<center>
<!--
<input type="button" name="button" class="ui-save-button" value="VIEW PDF" onclick="submit_questionnaire();" style="opacity:0.80" />
<input type="button" name="button" class="ui-save-button" value="SAVE" onclick="save_document();" style="opacity:0.80" />-->
<style type="text/css">
.ui-savex-button{
background: #2855c1; /* Old browsers */
background: -moz-linear-gradient(top, #2855c1 0%, #112f85 100%); /* FF3.6+ */
background: -webkit-gradient(linear, left top, left bottom, color-stop(0%,#2855c1), color-stop(100%,#112f85)); /* Chrome,Safari4+ */
background: -webkit-linear-gradient(top, #2855c1 0%,#112f85 100%); /* Chrome10+,Safari5.1+ */
background: -o-linear-gradient(top, #2855c1 0%,#112f85 100%); /* Opera 11.10+ */
background: -ms-linear-gradient(top, #2855c1 0%,#112f85 100%); /* IE10+ */
background: linear-gradient(to bottom, #2855c1 0%,#112f85 100%); /* W3C */
filter: progid:DXImageTransform.Microsoft.gradient( startColorstr='#2855c1', endColorstr='#112f85',GradientType=0 ); /* IE6-9 */
border:1px solid #071847;
border-radius:3px;
color:#FFF !important;
}
.ui-savex-button:hover{
box-shadow:inset 0px 2px 20px rgba(169, 194, 255, 0.49);
-moz-box-shadow:inset 0px 2px 20px rgba(169, 194, 255, 0.49);
-webkit-box-shadow:inset 0px 2px 20px rgba(169, 194, 255, 0.49);
border:1px solid #ffffff;
}
</style>
<input type="button" class="ui-savex-button" name="save" value="SAVE" onclick="save_user_document();" style="padding:12px 21px 12px 21px; cursor:pointer;" />
<input type="button" class="ui-savex-button" name="submit" value="SAVE & SEND" onclick="submit_questionnaire();" style="padding:12px 21px 12px 21px; cursor:pointer;" />
</center>
<hr />
<br />
</form>
</div>
</div>
<div class="sidebar">
<div class="sidebar_">
</div>
</div>
<div style="clear:both"></div>
<div style="width:100%;">
<center>
<div style="display:inline-block;">
<?php require_once('../footer.php'); ?>
</div>
</center>
</div>