18F/Paid-Leave-Prototype

[
  {
    "type": "title",
    "value": "Claim information"
  },
  {
    "key": "information.reason",
    "htmlClass": "information reason"
  },
  {
    "key": "information.benefits_start",
    "type": "date",
    "htmlClass": "information benefits_start"
  },
  {
    "type": "title",
    "value": "Person claiming benefits (claimant)"
  },
  {
    "type": "section-title",
    "value": "Name"
  },
  {
    "key": "claimant.name.first",
    "htmlClass": "claimant name name-first"
  },
  {
    "key": "claimant.name.middle",
    "htmlClass": "claimant name name-middle"
  },
  {
    "key": "claimant.name.last",
    "htmlClass": "claimant name name-last"
  },
  {
    "type": "section-title",
    "value": "Home address"
  },
  {
    "key": "claimant.address.street",
    "htmlClass": "claimant address street"
  },
  {
    "key": "claimant.address.city",
    "htmlClass": "claimant address city-state-zip city"
  },
  {
    "key": "claimant.address.state",
    "htmlClass": "claimant address city-state-zip state"
  },
  {
    "key": "claimant.address.zip",
    "htmlClass": "claimant address city-state-zip zip"
  },
  {
    "key": "claimant.address.country",
    "htmlClass": "claimant address country"
  },
  {
    "key": "claimant.email",
    "htmlClass": "claimant email"
  },
  {
    "key": "claimant.ssn",
    "htmlClass": "claimant ssn"
  },
  {
    "key": "claimant.birthdate",
    "type": "date",
    "htmlClass": "claimant birthdate"
  },
  {
    "key": "claimant.language",
    "htmlClass": "claimant language"
  },
  {
    "key": "claimant.telephone",
    "htmlClass": "claimant telephone"
  },
  {
    "key": "claimant.alternative_caretaker",
    "htmlClass": "claimant",
    "type": "radios"
  },
  {
    "type": "title",
    "value": "Employment"
  },
  {
    "type": "section-title",
    "value": "Claimant’s employer"
  },
  {
    "key": "employment.employer.name",
    "htmlClass": "employment employer name"
  },
  {
    "key": "employment.employer.address.street",
    "htmlClass": "employment employer address"
  },
  {
    "key": "employment.employer.address.city",
    "htmlClass": "employment employer address city city-state-zip"
  },
  {
    "key": "employment.employer.address.state",
    "htmlClass": "employment employer address state city-state-zip"
  },
  {
    "key": "employment.employer.address.zip",
    "htmlClass": "employment employer address zip city-state-zip"
  },
  {
    "key": "employment.benefits_end",
    "type": "date",
    "htmlClass": "employment"
  },
  {
    "key": "employment.continue_work",
    "htmlClass": "employment",
    "type": "radios"
  },
  {
    "key": "employment.workers_comp",
    "htmlClass": "employment",
    "type": "radios"
  },
  {
    "key": "employment.disclose",
    "htmlClass": "employment",
    "type": "radios"
  },
  {
    "type": "title",
    "value": "Dependent",
    "htmlClass": "dependent"
  },
  {
    "type": "instructions",
    "value": "This information is only required for claimants who are either bonding with a child or caring for someone other than themselves.",
    "htmlClass": "dependent"
  },
  {
    "type": "section-title",
    "value": "Dependent’s name",
    "htmlClass": "dependent"
  },
  {
    "key": "dependent.name.first",
    "htmlClass": "dependent name name-first"
  },
  {
    "key": "dependent.name.middle",
    "htmlClass": "dependent name name-middle"
  },
  {
    "key": "dependent.name.last",
    "htmlClass": "dependent name name-last"
  },
  {
    "type": "section-title",
    "htmlClass": "dependent",
    "value": "Dependent’s residence"
  },
  {
    "key": "dependent.address.street",
    "htmlClass": "dependent address street"
  },
  {
    "key": "dependent.address.city",
    "htmlClass": "dependent address city city-state-zip"
  },
  {
    "key": "dependent.address.state",
    "htmlClass": "dependent address state city-state-zip"
  },
  {
    "key": "dependent.address.zip",
    "htmlClass": "dependent address zip city-state-zip"
  },
  {
    "key": "dependent.address.country",
    "htmlClass": "dependent address country"
  },
  {
    "key": "dependent.relationship.type",
    "htmlClass": "dependent relationship type"
  },
  {
    "key": "dependent.relationship.documentation",
    "htmlClass": "dependent relationship documentation"
  },
  {
    "type": "title",
    "value": "Payment"
  },
  {
    "type": "instructions",
    "value": "Please select the method by which benefits should be paid. Direct deposit requires a bank account."
  },
  {
    "key": "payment.method",
    "htmlClass": "payment",
    "type": "radios"
  },
  {
    "key": "payment.direct_deposit.bank_name",
    "htmlClass": "payment direct_deposit"
  },
  {
    "key": "payment.direct_deposit.account_number",
    "htmlClass": "payment direct_deposit"
  },
  {
    "key": "payment.direct_deposit.routing_number",
    "htmlClass": "payment direct_deposit",
    "pattern": "^((0[0-9])|(1[0-2])|(2[1-9])|(3[0-2])|(6[1-9])|(7[0-2])|80)([0-9]{7})$"
  },
  {
    "key": "payment.direct_deposit.routing_number_2",
    "htmlClass": "payment direct_deposit",
    "pattern": "^((0[0-9])|(1[0-2])|(2[1-9])|(3[0-2])|(6[1-9])|(7[0-2])|80)([0-9]{7})$"
  },
  {
    "type": "button",
    "title": "Submit"
  }
]