{
'veteranFullName' => { 'first' => {
key: 'form1[0].#subform[82].VeteransFirstName[0]',
limit: 12,
question_num: 1,
question_text: "DECEASED VETERAN'S FIRST NAME"
},
'middleInitial' => {
key: 'form1[0].#subform[82].VeteransMiddleInitial1[0]',
question_num: 1,
limit: 1,
question_text: "DECEASED VETERAN'S MIDDLE INITIAL"
},
'last' => {
key: 'form1[0].#subform[82].VeteransLastName[0]',
limit: 18,
question_num: 1,
question_text: "DECEASED VETERAN'S LAST NAME"
},
'suffix' => {
key: 'form1[0].#subform[82].Suffix[0]',
question_num: 1,
limit: 0,
question_text: "DECEASED VETERAN'S SUFFIX"
}
},
'veteranSocialSecurityNumber' => {
'first' => {
key: 'form1[0].#subform[82].VeteransSocialSecurityNumber_FirstThreeNumbers[0]'
},
'second' => {
key: 'form1[0].#subform[82].VeteransSocialSecurityNumber_SecondTwoNumbers[0]'
},
'third' => {
key: 'form1[0].#subform[82].VeteransSocialSecurityNumber_LastFourNumbers[0]'
}
},
'vaFileNumber' => {
key: 'form1[0].#subform[82].VAFileNumber[0]',
question_num: 3
},
'veteranDateOfBirth' => {
'month' => {
key: 'form1[0].#subform[82].Veterans_DOBmonth[0]',
limit: 2,
question_num: 4,
question_suffix: 'A',
question_text: 'VETERAN/CLAIMANT\'S IDENTIFICATION INFORMATION > VETERAN\'S DATE OF BIRTH (MM-DD-YYYY)'
},
'day' => {
key: 'form1[0].#subform[82].Veterans_DOBday[0]',
limit: 2,
question_num: 4,
question_suffix: 'B',
question_text: 'VETERAN/CLAIMANT\'S IDENTIFICATION INFORMATION > VETERAN\'S DATE OF BIRTH (MM-DD-YYYY)'
},
'year' => {
key: 'form1[0].#subform[82].Veterans_DOByear[0]',
limit: 4,
question_num: 4,
question_suffix: 'C',
question_text: 'VETERAN/CLAIMANT\'S IDENTIFICATION INFORMATION > VETERAN\'S DATE OF BIRTH (MM-DD-YYYY)'
}
},
'deathDate' => {
'month' => {
key: 'form1[0].#subform[82].Veterans_DateOfDeathmonth[0]',
limit: 2,
question_num: 5,
question_suffix: 'A',
question_text: 'VETERAN/CLAIMANT\'S IDENTIFICATION INFORMATION > VETERAN\'S DATE OF DEATH (MM-DD-YYYY)'
},
'day' => {
key: 'form1[0].#subform[82].Veterans_DateofDeathday[0]',
limit: 2,
question_num: 5,
question_suffix: 'B',
question_text: 'VETERAN/CLAIMANT\'S IDENTIFICATION INFORMATION > VETERAN\'S DATE OF DEATH (MM-DD-YYYY)'
},
'year' => {
key: 'form1[0].#subform[82].Veterans_DateofDeathyear[0]',
limit: 4,
question_num: 5,
question_suffix: 'C',
question_text: 'VETERAN/CLAIMANT\'S IDENTIFICATION INFORMATION > VETERAN\'S DATE OF DEATH (MM-DD-YYYY)'
}
},
'burialDate' => {
'month' => {
key: 'form1[0].#subform[82].Veterans_Date_of_Burial_Month[0]',
limit: 2,
question_num: 6,
question_suffix: 'A',
question_text: 'VETERAN/CLAIMANT\'S IDENTIFICATION INFORMATION > VETERAN\'S DATE OF BURIAL (MM-DD-YYYY)'
},
'day' => {
key: 'form1[0].#subform[82].Veterans_Date_of_Burial_Day[0]',
limit: 2,
question_num: 6,
question_suffix: 'B',
question_text: 'VETERAN/CLAIMANT\'S IDENTIFICATION INFORMATION > VETERAN\'S DATE OF BURIAL (MM-DD-YYYY)'
},
'year' => {
key: 'form1[0].#subform[82].Veterans_Date_of_Burial_Year[0]',
limit: 4,
question_num: 6,
question_suffix: 'C',
question_text: 'VETERAN/CLAIMANT\'S IDENTIFICATION INFORMATION > VETERAN\'S DATE OF BURIAL (MM-DD-YYYY)'
}
}, 'claimantFullName' => { 'first' => {
key: 'form1[0].#subform[82].ClaimantsFirstName[0]',
limit: 12,
question_num: 7,
question_text: "CLAIMANT'S FIRST NAME"
},
'middleInitial' => {
key: 'form1[0].#subform[82].ClaimantsMiddleInitial1[0]'
},
'last' => {
key: 'form1[0].#subform[82].ClaimantsLastName[0]',
limit: 18,
question_num: 7,
question_text: "CLAIMANT'S LAST NAME"
},
'suffix' => {
key: 'form1[0].#subform[82].ClaimantSuffix[0]',
question_num: 7,
limit: 0,
question_text: "CLAIMANT'S SUFFIX"
}
},
'claimantSocialSecurityNumber' => {
'first' => {
key: 'form1[0].#subform[82].Claimants_SocialSecurityNumber_FirstThreeNumbers[0]'
},
'second' => {
key: 'form1[0].#subform[82].Claimants_SocialSecurityNumber_SecondTwoNumbers[0]'
},
'third' => {
key: 'form1[0].#subform[82].Claimants_SocialSecurityNumber_LastFourNumbers[0]'
}
},
'claimantDateOfBirth' => {
'month' => {
key: 'form1[0].#subform[82].Claimants_DOBmonth[0]',
limit: 2,
question_num: 9,
question_suffix: 'A',
question_text: 'VETERAN/CLAIMANT\'S IDENTIFICATION INFORMATION > CLAIMANT\'S DATE OF BIRTH (MM-DD-YYYY)'
},
'day' => {
key: 'form1[0].#subform[82].Claimants_DOBday[0]',
limit: 2,
question_num: 9,
question_suffix: 'B',
question_text: 'VETERAN/CLAIMANT\'S IDENTIFICATION INFORMATION > CLAIMANT\'S DATE OF BIRTH (MM-DD-YYYY)'
},
'year' => {
key: 'form1[0].#subform[82].Claimants_DOByear[0]',
limit: 4,
question_num: 9,
question_suffix: 'C',
question_text: 'VETERAN/CLAIMANT\'S IDENTIFICATION INFORMATION > CLAIMANT\'S DATE OF BIRTH (MM-DD-YYYY)'
}
},
'claimantAddress' => {
'street' => {
key: 'form1[0].#subform[82].CurrentMailingAddress_NumberAndStreet[0]',
limit: 30,
question_num: 10,
question_text: "CLAIMANT'S ADDRESS - STREET"
},
'street2' => {
key: 'form1[0].#subform[82].CurrentMailingAddress_ApartmentOrUnitNumber[0]',
limit: 5,
question_num: 10,
question_text: "CLAIMANT'S ADDRESS - APT/UNIT NO."
},
'city' => {
key: 'form1[0].#subform[82].CurrentMailingAddress_City[0]',
limit: 18,
question_num: 10,
question_text: "CLAIMANT'S ADDRESS - CITY"
},
'state' => {
key: 'form1[0].#subform[82].CurrentMailingAddress_StateOrProvince[0]',
limit: 2,
question_num: 10,
question_text: "CLAIMANT'S ADDRESS - STATE"
},
'country' => {
key: 'form1[0].#subform[82].CurrentMailingAddress_Country[0]',
limit: 2,
question_num: 10,
question_text: "CLAIMANT'S ADDRESS - COUNTRY"
},
'postalCode' => {
'firstFive' => {
key: 'form1[0].#subform[82].CurrentMailingAddress_ZIPOrPostalCode_FirstFiveNumbers[0]',
limit: 5,
question_num: 10,
question_text: "CLAIMANT'S ADDRESS - POSTAL CODE - FIRST FIVE"
},
'lastFour' => {
key: 'form1[0].#subform[82].CurrentMailingAddress_ZIPOrPostalCode_LastFourNumbers[0]',
limit: 4,
question: 10,
question_text: "CLAIMANT's ADDRESS - POSTAL CODE - LAST FOUR"
}
}
},
'claimantPhone' => {
'first' => {
key: 'form1[0].#subform[82].TelephoneNumber_AreaCode[0]'
},
'second' => {
key: 'form1[0].#subform[82].TelephoneNumber_FirstThreeNumbers[0]'
},
'third' => {
key: 'form1[0].#subform[82].TelephoneNumber_LastFourNumbers[0]'
}
},
'claimantIntPhone' => {
key: 'form1[0].#subform[82].IntTelephoneNumber[0]',
question_num: 11,
question_text: "CLAIMANT'S INTERNATIONAL PHONE NUMBER",
limit: 0 },
'claimantEmail' => {
key: 'form1[0].#subform[82].E-Mail_Address[0]',
limit: 31,
question_num: 12,
question_text: 'E-MAIL ADDRESS'
},
'relationshipToVeteran' => {
'spouse' => {
key: 'form1[0].#subform[82].CheckboxSpouse[0]'
},
'child' => {
key: 'form1[0].#subform[82].CheckboxChild[0]'
},
'parent' => {
key: 'form1[0].#subform[82].CheckboxParent[0]'
},
'executor' => {
key: 'form1[0].#subform[82].CheckboxExecutor[0]'
},
'funeralDirector' => {
key: 'form1[0].#subform[82].CheckboxFuneralHome[0]'
},
'otherFamily' => {
key: 'form1[0].#subform[82].CheckboxOther[0]'
}
},
'toursOfDuty' => {
limit: 3,
first_key: 'rank',
'dateRangeStart' => {
key: "form1[0].#subform[82].DATE_ENTERED_SERVICE[#{ITERATOR}]",
question_num: 14,
question_suffix: 'A',
question_text: 'ENTERED SERVICE (date)',
format: 'date'
},
'placeOfEntry' => {
key: "form1[0].#subform[82].PLACE[#{ITERATOR}]",
limit: 14,
question_num: 14,
question_suffix: 'A',
question_text: 'ENTERED SERVICE (place)'
},
'militaryServiceNumber' => {
key: "form1[0].#subform[82].SERVICE_NUMBER[#{ITERATOR}]",
limit: 12,
question_num: 14,
question_suffix: 'B',
question_text: 'SERVICE NUMBER'
},
'dateRangeEnd' => {
key: "form1[0].#subform[82].DATE_SEPARATED_SERVICE[#{ITERATOR}]",
question_num: 14,
question_suffix: 'C',
question_text: 'SEPARATED FROM SERVICE (date)',
format: 'date'
},
'placeOfSeparation' => {
key: "form1[0].#subform[82].PLACE_SEPARATED[#{ITERATOR}]",
question_num: 14,
question_suffix: 'C',
question_text: 'SEPARATED FROM SERVICE (place)',
limit: 15
},
'rank' => {
key: "form1[0].#subform[82].GRADE_RANK_OR_RATING[#{ITERATOR}]",
question_num: 14,
question_suffix: 'D',
question_text: 'GRADE, RANK OR RATING, ORGANIZATION AND BRANCH OF SERVICE',
limit: 31
},
'unit' => {
key: "form1[0].#subform[82].GRADE_RANK_OR_RATING_UNIT[#{ITERATOR}]",
question_num: 14,
question_suffix: 'D',
question_text: 'UNIT',
limit: 0
}
},
'previousNames' => {
key: 'form1[0].#subform[82].OTHER_NAME_VETERAN_SERVED_UNDER[0]',
question_num: 15,
question_text: 'IF VETERAN SERVED UNDER NAME OTHER THAN THAT SHOWN IN ITEM 1, GIVE FULL NAME AND SERVICE RENDERED UNDER THAT NAME',
limit: 180
},
'veteranSocialSecurityNumber2' => {
'first' => {
key: 'form1[0].#subform[83].#subform[84].VeteransSocialSecurityNumber_FirstThreeNumbers[1]'
},
'second' => {
key: 'form1[0].#subform[83].#subform[84].VeteransSocialSecurityNumber_SecondTwoNumbers[1]'
},
'third' => {
key: 'form1[0].#subform[83].#subform[84].VeteransSocialSecurityNumber_LastFourNumbers[1]'
}
},
'finalRestingPlace' => { 'location' => {
'cemetery' => {
key: 'form1[0].#subform[83].#subform[84].RestingPlaceCemetery[5]'
},
'privateResidence' => {
key: 'form1[0].#subform[83].#subform[84].RestingPlacePrivateResidence[5]'
},
'mausoleum' => {
key: 'form1[0].#subform[83].#subform[84].RestingPlaceMausoleum[5]'
},
'other' => {
key: 'form1[0].#subform[83].#subform[84].RestingPlaceOther[5]'
}
},
'other' => {
limit: 58,
question_num: 16,
question_text: "PLACE OF BURIAL PLOT, INTERMENT SITE, OR FINAL RESTING PLACE OF DECEASED VETERAN'S REMAINS",
key: 'form1[0].#subform[83].#subform[84].PLACE_OF_DEATH[0]'
}
},
'hasNationalOrFederal' => {
key: 'form1[0].#subform[37].FederalCemeteryYES[0]'
},
'noNationalOrFederal' => {
key: 'form1[0].#subform[37].FederalCemeteryNo[0]'
},
'name' => {
key: 'form1[0].#subform[37].FederalCemeteryName[0]',
limit: 50
},
'cemetaryLocationQuestionCemetery' => {
key: 'form1[0].#subform[37].HasStateCemetery[2]'
},
'cemetaryLocationQuestionTribal' => {
key: 'form1[0].#subform[37].HasTribalTrust[2]'
},
'cemetaryLocationQuestionNone' => {
key: 'form1[0].#subform[37].NoStateCemetery[2]'
},
'stateCemeteryOrTribalTrustName' => {
key: 'form1[0].#subform[37].StateCemeteryOrTribalTrustName[2]',
limit: 33
},
'stateCemeteryOrTribalTrustZip' => {
key: 'form1[0].#subform[37].StateCemeteryOrTribalTrustZip[2]'
},
'hasGovtContributions' => {
key: 'form1[0].#subform[37].GovContributionYES[0]'
},
'noGovtContributions' => {
key: 'form1[0].#subform[37].GovContributionNo[0]'
},
'amountGovtContribution' => {
key: 'form1[0].#subform[37].AmountGovtContribution[0]',
question_num: 19,
question_suffix: 'B',
dollar: true,
question_text: 'AMOUNT OF GOVERNMENT OR EMPLOYER CONTRIBUTION',
limit: 5
},
'burialAllowanceRequested' => {
'checkbox' => {
'nonService' => {
key: 'form1[0].#subform[83].Non-Service-Connected[0]'
},
'service' => {
key: 'form1[0].#subform[83].Service-Connected[0]'
},
'unclaimed' => {
key: 'form1[0].#subform[83].UnclaimedRemains[0]'
}
}
},
'locationOfDeath' => {
'checkbox' => {
'nursingHomeUnpaid' => {
key: 'form1[0].#subform[83].NursingHomeOrResidenceNotPaid[1]'
},
'nursingHomePaid' => {
key: 'form1[0].#subform[83].NursingHomeOrResidencePaid[1]'
},
'vaMedicalCenter' => {
key: 'form1[0].#subform[83].VaMedicalCenter[1]'
},
'stateVeteransHome' => {
key: 'form1[0].#subform[83].StateVeteransHome[1]'
},
'other' => {
key: 'form1[0].#subform[83].DeathOccurredOther[1]'
}
},
'other' => {
key: 'form1[0].#subform[37].DeathOccurredOtherSpecify[1]',
question_num: 20,
question_suffix: 'B',
question_text: "WHERE DID THE VETERAN'S DEATH OCCUR?",
limit: 32
},
'placeAndLocation' => {
limit: 42,
question_num: 20,
question_suffix: 'B',
question_text: "PLEASE PROVIDE VETERAN'S SPECIFIC PLACE OF DEATH INCLUDING THE NAME AND LOCATION OF THE NURSING HOME, VA MEDICAL CENTER OR STATE VETERAN FACILITY.",
key: 'form1[0].#subform[37].DeathOccurredPlaceAndLocation[1]'
}
},
'hasPreviouslyReceivedAllowance' => {
key: 'form1[0].#subform[83].PreviousAllowanceYes[0]'
},
'noPreviouslyReceivedAllowance' => {
key: 'form1[0].#subform[83].PreviousAllowanceNo[0]'
},
'hasBurialExpenseResponsibility' => {
key: 'form1[0].#subform[83].ResponsibleForBurialCostYes[0]'
},
'noBurialExpenseResponsibility' => {
key: 'form1[0].#subform[83].ResponsibleForBurialCostNo[0]'
},
'hasConfirmation' => {
key: 'form1[0].#subform[83].certifyUnclaimedYes[0]'
},
'noConfirmation' => {
key: 'form1[0].#subform[83].certifyUnclaimedNo[0]'
},
'hasPlotExpenseResponsibility' => {
key: 'form1[0].#subform[83].ResponsibleForPlotIntermentCostYes[0]'
},
'noPlotExpenseResponsibility' => {
key: 'form1[0].#subform[83].ResponsibleForPlotIntermentCostNo[0]'
},
'hasTransportation' => {
key: 'form1[0].#subform[83].ResponsibleForTransportationYes[0]'
},
'noTransportation' => {
key: 'form1[0].#subform[83].ResponsibleForTransportationNo[0]'
},
'hasProcessOption' => {
key: 'form1[0].#subform[83].WantClaimFDCProcessedYes[0]'
},
'noProcessOption' => {
key: 'form1[0].#subform[83].WantClaimFDCProcessedNo[0]'
},
'signature' => {
key: 'form1[0].#subform[83].CLAIMANT_SIGNATURE[0]',
limit: 45,
question_num: 25,
question_text: 'SIGNATURE OF CLAIMANT',
question_suffix: 'A'
},
'claimantPrintedName' => {
key: 'form1[0].#subform[83].ClaimantPrintedName[0]',
limit: 45,
question_num: 25,
question_text: 'Printed Name of Claimant',
question_suffix: 'B'
},
'firmNameAndAddr' => {
key: 'form1[0].#subform[83].FirmNameAndAddress[0]',
limit: 90,
question_num: 26,
question_suffix: 'B',
question_text: 'FULL NAME AND ADDRESS OF THE FIRM, CORPORATION, OR STATE AGENCY FILING AS CLAIMANT'
},
'officialPosition' => {
key: 'form1[0].#subform[83].OfficialPosition[0]',
limit: 90,
question_num: 26,
question_suffix: 'B',
question_text: 'OFFICIAL POSITION OF PERSON SIGNING ON BEHALF OF FIRM, CORPORATION OR STATE AGENCY'
},
'veteranSocialSecurityNumber3' => {
'first' => {
key: 'form1[0].#subform[83].#subform[84].VeteransSocialSecurityNumber_FirstThreeNumbers[2]'
},
'second' => {
key: 'form1[0].#subform[83].#subform[84].VeteransSocialSecurityNumber_SecondTwoNumbers[2]'
},
'third' => {
key: 'form1[0].#subform[83].#subform[84].VeteransSocialSecurityNumber_LastFourNumbers[2]'
}
}
}.freeze