{"_id":"66918e345a565cb5847f1852","type":"form","tags":[],"owner":"5f9acba5f1b659b9e06350e4","components":[{"label":"Top of Form","columns":[{"components":[{"label":"<font color=\"red\">authorizationToken</font>","key":"authorizationToken","type":"hidden","input":true,"tableView":false,"hideOnChildrenHidden":false}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2},{"components":[{"label":"<font color=\"green\">agencyFormId</font>","key":"agencyFormId","type":"hidden","input":true,"tableView":false,"hideOnChildrenHidden":false}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2},{"components":[{"label":"min/max","persistent":"client-only","calculateServer":true,"trigger":{"init":true,"server":true},"dataSrc":"url","fetch":{"url":"{{ config.PAYGOV_ENV }}/public/api/v1/minmaxamount/{{ data.agencyFormId }}","method":"get","headers":[{"key":"X-Paygov-Authorization-Token","value":"{{ data.authorizationToken }}"}],"forwardHeaders":true,"authenticate":false},"key":"minMax","type":"datasource","input":true,"tableView":false,"hideOnChildrenHidden":false,"lockKey":true,"source":"5eac84259b53ff041c170ee7","isNew":true}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2},{"components":[],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2}],"tableView":false,"key":"topOfForm","type":"columns","input":false,"lockKey":true,"source":"5e3b1d285e65135702af3f4e","isNew":true,"hideOnChildrenHidden":false},{"label":"Columns","columns":[{"components":[{"label":"HTML","tag":"img","attrs":[{"attr":"src","value":"{{ config.STATIC_ASSETS_ENV }}/VAHRC/images/vahrc_logo.jpg"},{"attr":"alt","value":"U.S. Department of Veterans Affairs"},{"attr":"title","value":"U.S. Department of Veterans Affairs"}],"refreshOnChange":false,"tableView":false,"key":"html","type":"htmlelement","input":false,"hideOnChildrenHidden":false}],"width":3,"offset":0,"push":0,"pull":0,"size":"xs","currentWidth":3},{"components":[],"width":6,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":6}],"tableView":false,"key":"columns2","type":"columns","input":false,"hideOnChildrenHidden":false},{"label":"HTML","tag":"h3","attrs":[{"attr":"","value":""}],"content":"VA Medical Care Copayment","refreshOnChange":false,"tableView":false,"key":"html1","type":"htmlelement","input":false},{"label":"HTML","attrs":[{"attr":"","value":""}],"content":"<br>Please have a copy of the Veteran Patient Statement sent from Department of Veterans Affairs in front of you to enter the correct information.\n<br><br>For assistance with this form please call 888-827-4817\n<br><br><font color=\"red\">*</font> Required Field<br>&nbsp;","refreshOnChange":false,"tableView":false,"key":"html2","type":"htmlelement","input":false},{"title":"Veteran Information","collapsible":true,"tableView":false,"key":"veteranInformation","type":"panel","label":"Veteran Information","input":false,"components":[{"label":"Columns","columns":[{"components":[{"label":"Veteran's First Name","tableView":true,"calculateServer":true,"validate":{"required":true,"custom":"valid = pgFormioGlobal().validateText(input);","maxLength":100},"key":"veteransFirstName","type":"textfield","input":true,"hideOnChildrenHidden":false}],"width":5,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":5},{"components":[{"label":"Middle Initial","tableView":true,"calculateServer":true,"validate":{"custom":"valid=pgFormioGlobal().validateText(input);","maxLength":1},"key":"middleInitial","type":"textfield","input":true,"hideOnChildrenHidden":false}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2},{"components":[{"label":"Veteran's Last Name","tableView":true,"calculateServer":true,"validate":{"required":true,"custom":"valid = pgFormioGlobal().validateText(input);","maxLength":100},"key":"veteransLastName","type":"textfield","input":true,"hideOnChildrenHidden":false}],"size":"md","width":5,"offset":0,"push":0,"pull":0,"currentWidth":5}],"tableView":false,"key":"columns3","type":"columns","input":false,"hideOnChildrenHidden":false},{"label":"HTML","attrs":[{"attr":"","value":""}],"content":"<br>Account Number<br>\n<a href=\"{{ config.STATIC_ASSETS_ENV }}/VAHRC/help/vahrc_examplestatement.pdf\" target=\"_blank\">Where do I find my VA Account Number?</a>","refreshOnChange":false,"tableView":false,"key":"html3","type":"htmlelement","input":false,"hideOnChildrenHidden":false},{"label":"Columns","columns":[{"components":[{"label":"Part 1","tableView":true,"calculateServer":true,"validateOn":"blur","validate":{"required":true,"custom":"var regEx = /^\\d{3}$/;\nvalid = (input === \"\" || input === null || input === undefined || regEx.test(input)) ? true : \"Invalid Part 1 of Statement Account Number. Please verify.\";","maxLength":3},"key":"part1","type":"textfield","input":true,"hideOnChildrenHidden":false}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2},{"components":[{"label":"Part 2","tableView":true,"calculateServer":true,"validateOn":"blur","validate":{"required":true,"custom":"var regEx = /^\\d{4}$/;\nvalid = (input === \"\" || input === null || input === undefined || regEx.test(input)) ? true : \"Invalid Part 2 of Statement Account Number. Please verify.\";","maxLength":4},"key":"part2","type":"textfield","input":true,"hideOnChildrenHidden":false}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2},{"components":[{"label":"Part 3","tableView":true,"calculateServer":true,"validateOn":"blur","validate":{"required":true,"custom":"var regEx = /^\\d{4}$/;\nvalid = (input === \"\" || input === null || input === undefined || regEx.test(input)) ? true : \"Invalid Part 3 of Statement Account Number. Please verify.\";","maxLength":4},"key":"part3","type":"textfield","input":true,"hideOnChildrenHidden":false}],"size":"md","width":2,"offset":0,"push":0,"pull":0,"currentWidth":2},{"components":[{"label":"Part 4","tableView":true,"calculateServer":true,"validateOn":"blur","validate":{"required":true,"custom":"var regEx = /^\\d{5}$/;\nvalid = (input === \"\" || input === null || input === undefined || regEx.test(input)) ? true : \"Invalid Part 4 of Statement Account Number. Please verify.\";","maxLength":5},"key":"part4","type":"textfield","input":true,"hideOnChildrenHidden":false}],"size":"md","width":2,"offset":0,"push":0,"pull":0,"currentWidth":2},{"components":[{"label":"Part 5","tableView":true,"calculateServer":true,"validateOn":"blur","validate":{"required":true,"custom":"var regEx = /^[a-z]{1,5}$/i;\nvalid = (input === \"\" || input === null || input === undefined || regEx.test(input)) ? true : \"Invalid Part 5 of Statement Account Number. Please verify.\";","maxLength":5},"key":"part5","type":"textfield","input":true,"hideOnChildrenHidden":false}],"size":"md","width":2,"offset":0,"push":0,"pull":0,"currentWidth":2}],"tableView":false,"key":"columns4","type":"columns","input":false,"hideOnChildrenHidden":false}],"collapsed":false},{"title":"Payer Information","collapsible":true,"tableView":false,"key":"payerInformation","type":"panel","label":"Payer Information","input":false,"components":[{"label":"HTML","attrs":[{"attr":"","value":""}],"content":"The following questions must reflect the identity of the person making the payment<br>&nbsp;","refreshOnChange":false,"tableView":false,"key":"html4","type":"htmlelement","input":false},{"label":"Payer's Full Name","tableView":true,"calculateServer":true,"validate":{"required":true,"custom":"var regEx = /^[A-Za-z\\s]+$/i;\nvalid = (input === \"\" || input === null || regEx.test(input)) ? true : \"Field contains invalid characters.\";","maxLength":100},"key":"partyGivenName","type":"textfield","input":true},{"label":"Columns","columns":[{"components":[{"label":"Payer's Phone Number","tableView":true,"calculateServer":true,"validateOn":"blur","validate":{"required":true,"custom":"if (input === \"\" || input === null || input === undefined) {\r\n  valid = true;\r\n} else {\r\n  var regEx = /^\\(?\\d{3}\\)?\\s?-?\\d{3}-?\\d{4}$/;\r\n  if (!regEx.test(input)) {\r\n    valid = \"Invalid Telephone Number\";\r\n  } else {\r\n    var str = input.replace(/[^\\d]/g, \"\");\r\n    var newValue = \"(\"+ str.substr(0,3) + \") \" + str.substr(3,3) + \"-\" + str.substr(6);\r\n    if (typeof instance != \"undefined\") {\r\n     instance.setValue(newValue);\r\n    }\r\n    else {\r\n      data[component.key] = newValue;\r\n    }\r\n    valid = true;\r\n  }\r\n}"},"key":"payersTelephoneNumber","type":"textfield","input":true,"lockKey":true,"source":"5e3b1d285e65135702af3f4e","isNew":true,"hideOnChildrenHidden":false},{"label":"Payer's Email Address:","tableView":true,"calculateServer":true,"validateOn":"blur","validate":{"custom":"valid = pgFormioGlobal().validateEmail(input);"},"key":"partyEmail","type":"textfield","input":true,"hideOnChildrenHidden":false}],"width":6,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":6},{"components":[],"width":6,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":6}],"key":"columns","type":"columns","tableView":false,"input":false,"hideOnChildrenHidden":false}],"collapsed":false},{"title":"Payment Information","collapsible":true,"tableView":false,"key":"paymentInformation","type":"panel","label":"Payment Information","input":false,"components":[{"label":"Columns","columns":[{"components":[{"label":"Payment Amount","mask":false,"spellcheck":true,"tableView":false,"currency":"USD","inputFormat":"plain","calculateServer":true,"validate":{"required":true,"custom":"if (input < parseFloat(data.minMax.minAmount)) {\r\n  valid = \"Your payment is below the allowed amount. Please enter a higher dollar amount.\";\r\n} else if (input > parseFloat(data.minMax.maxAmount)) {\r\n  valid = \"Your payment is above the maximum allowed amount. Please enter a lower dollar amount.\";\r\n} else {\r\n  valid = true;\r\n}\r\n\r\n/*\r\nif (valid && input > 1000) {\r\n  if (!data.checkBox) {\r\n    alert(\"You have entered an amount greater than $1000.00.  Please confirm this is the amount you intend to pay.\");\r\n    data.hiddenField = true;\r\n  }\r\n} else {\r\n  data.hiddenField = false;\r\n}\r\n*/"},"key":"RemittanceNetAmount","type":"currency","input":true,"delimiter":true,"hideOnChildrenHidden":false},{"label":"Hidden Field","persistent":false,"calculateServer":true,"key":"hiddenField","type":"hidden","input":true,"tableView":false,"hideOnChildrenHidden":false}],"width":6,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":6},{"components":[],"width":6,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":6}],"key":"columns5","type":"columns","tableView":false,"input":false,"hideOnChildrenHidden":false}],"collapsed":false},{"label":"HTML","attrs":[{"attr":"","value":""}],"content":"<br>This form should only be used to pay VA health care copayments and/or VA prescription copayments. Please verify Veteran name and account number match information on the Veteran Patient Statement before submitting your payment. Incorrect information or wrong form used will delay payment posting.\n<br><br>If you do not have a statement or need assistance with this form, please call <strong> 888-827-4817 Monday-Friday, between 8am-8pm(EST).</strong>","refreshOnChange":false,"tableView":false,"key":"html5","type":"htmlelement","input":false},{"label":"SBU Footer","tableView":true,"form":"5fc7c311de457463ee152fb3","reference":false,"key":"sbuFooter","customConditional":"show = instance.options.pdf;","type":"form","input":true,"lockKey":true,"source":"5eac84259b53ff041c170ee7","isNew":true,"revision":0,"components":[{"label":"HTML","tag":"p style=\"font-size: 11px\"","className":"","attrs":[{"attr":"","value":""}],"content":"<br><br>\r\n\r\nThe content of this document may contain Sensitive But Unclassified (SBU) data and/or Controlled Unclassified Information (CUI).\r\n","refreshOnChange":false,"customClass":"","hidden":false,"modalEdit":false,"key":"sbu_label","tags":[],"properties":{},"conditional":{"eq":"","json":""},"customConditional":"","logic":[],"attributes":{},"overlay":{"style":"","page":"","left":"","top":"","width":"","height":""},"type":"htmlelement","input":false,"tableView":false,"placeholder":"","prefix":"","suffix":"","multiple":false,"protected":false,"unique":false,"persistent":false,"clearOnHide":true,"refreshOn":"","redrawOn":"","labelPosition":"top","description":"","errorLabel":"","tooltip":"","hideLabel":false,"tabindex":"","disabled":false,"autofocus":false,"dbIndex":false,"customDefaultValue":"","calculateValue":"","calculateServer":false,"validateOn":"change","validate":{"required":false,"custom":"","customPrivate":false,"strictDateValidation":false,"multiple":false,"unique":false},"allowCalculateOverride":false,"encrypted":false,"showCharCount":false,"showWordCount":false,"allowMultipleMasks":false,"id":"e56fbt3"},{"label":"HiddenTestField","calculateValue":"value = \"\";","calculateServer":true,"key":"hiddenTestField","type":"hidden","input":true,"tableView":false,"placeholder":"","prefix":"","customClass":"","suffix":"","multiple":false,"protected":false,"unique":false,"persistent":true,"hidden":false,"clearOnHide":true,"refreshOn":"","redrawOn":"","modalEdit":false,"labelPosition":"top","description":"","errorLabel":"","tooltip":"","hideLabel":false,"tabindex":"","disabled":false,"autofocus":false,"dbIndex":false,"customDefaultValue":"","widget":{"type":"input"},"attributes":{},"validateOn":"change","validate":{"required":false,"custom":"","customPrivate":false,"strictDateValidation":false,"multiple":false,"unique":false},"conditional":{"eq":""},"overlay":{"style":"","left":"","top":"","width":"","height":""},"allowCalculateOverride":false,"encrypted":false,"showCharCount":false,"showWordCount":false,"properties":{},"allowMultipleMasks":false,"inputType":"hidden","id":"em1zpzb"}]},{"label":"Standard Buttons","columns":[{"components":[{"label":"Continue","action":"custom","showValidations":false,"block":true,"customClass":"usa-button","tableView":false,"key":"submit","customConditional":"show = !data.showReassignButton ? true : data.showSubmitButton;","type":"button","custom":"if (instance.root.checkValidity(null, true)) {\r\n  if(data.RemittanceNetAmount > 1000) {\r\n    if (confirm(\"You have entered an amount greater than $1000.00.  Please confirm this is the amount you intend to pay. \\n\\n Click 'OK' to continue or 'Cancel' to enter a different amount.\")) {\r\n      instance.emit('submitButton');\r\n    }\r\n  } else {\r\n    instance.emit('submitButton');\r\n  }\r\n} else {\r\n  instance.emit('submitButton');\r\n}","input":true,"hideOnChildrenHidden":false}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2},{"components":[{"label":"View PDF","action":"event","showValidations":false,"block":true,"customClass":"usa-button usa-button--outline","tableView":false,"key":"viewPdf","attributes":{"class":"usa-button--outline"},"type":"button","event":"viewPdf","input":true,"hideOnChildrenHidden":false}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2},{"components":[{"label":"Save","action":"event","showValidations":false,"block":true,"customClass":"usa-button usa-button--outline","tableView":false,"key":"save","customConditional":"show = data.showSaveButton;","type":"button","event":"save","input":true,"hideOnChildrenHidden":false}],"size":"md","width":2,"offset":0,"push":0,"pull":0,"currentWidth":2},{"components":[{"label":"Reassign","action":"event","showValidations":false,"block":true,"customClass":"usa-button usa-button--outline","tableView":false,"key":"reassign","customConditional":"show = data.showReassignButton;","type":"button","event":"reassign","input":true,"hideOnChildrenHidden":false}],"size":"md","width":2,"offset":0,"push":0,"pull":0,"currentWidth":2},{"components":[],"size":"md","width":2,"offset":0,"push":0,"pull":0,"currentWidth":2},{"components":[],"size":"md","width":2,"offset":0,"push":0,"pull":0,"currentWidth":2}],"tableView":false,"key":"standardButtons","type":"columns","input":false,"lockKey":true,"source":"5eac84253f388e59f3ba3b2c","isNew":true,"hideOnChildrenHidden":false},{"label":"Columns","columns":[{"components":[{"label":"accountNumberField","calculateValue":"value = data.part1+data.part2+data.part3+data.part4+data.part5;","calculateServer":true,"key":"accountNumberField","type":"hidden","spellcheck":true,"tableView":true,"input":true,"mask":false,"inputType":"text","inputFormat":"plain","hideOnChildrenHidden":false}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2},{"components":[{"label":"CCF 1","calculateServer":true,"key":"custom_field_1","type":"hidden","input":true,"tableView":true,"lockKey":true,"hideOnChildrenHidden":false,"mask":false,"inputFormat":"plain"}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2},{"components":[{"label":"CCF 2","calculateValue":"value = data.accountNumberField;","calculateServer":true,"key":"custom_field_2","type":"hidden","input":true,"tableView":true,"lockKey":true,"hideOnChildrenHidden":false,"mask":false,"inputFormat":"plain"}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2},{"components":[{"label":"CCF 3","calculateValue":"value = data.payersTelephoneNumber;","calculateServer":true,"key":"custom_field_3","type":"hidden","spellcheck":true,"tableView":true,"input":true,"lockKey":true,"hideOnChildrenHidden":false,"mask":false,"inputFormat":"plain"}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2},{"components":[{"label":"CCF 4","calculateValue":"value = data.partyEmail;","calculateServer":true,"key":"custom_field_4","type":"hidden","spellcheck":true,"tableView":true,"input":true,"lockKey":true,"hideOnChildrenHidden":false,"mask":false,"inputFormat":"plain"}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2},{"components":[{"label":"partyCountry","defaultValue":"USA","calculateServer":true,"key":"partyCountry","type":"hidden","spellcheck":true,"tableView":true,"input":true,"mask":false,"inputType":"text","inputFormat":"plain","hideOnChildrenHidden":false}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2}],"tableView":false,"key":"columns1","type":"columns","input":false,"hideOnChildrenHidden":false}],"revisions":"original","_vid":4,"_vnote":"(Source version:27, User:smartin, Build:12285465)","_vuser":"admin","title":"VA_HRC_v4","name":"vaHrcV4","path":"vahrcv4","display":"form","controller":"","properties":{"adobeMapper":"<form name=\"VA_HRC_v3\"> \t<subform name=\"page1\"> \t\t<field name=\"middlenameField\" key=\"middleInitial\" type=\"text\"/> \t\t<field name=\"accountNumberField\" key=\"accountNumberField\" type=\"text\"/> \t\t<field name=\"RemittanceNetAmount\" key=\"RemittanceNetAmount\" type=\"text\"/> \t\t<field name=\"lastnameField\" key=\"veteransLastName\" type=\"text\"/> \t\t<field name=\"firstnameField\" key=\"veteransFirstName\" type=\"text\"/> \t\t<field name=\"paymentMethod\" key=\"paymentMethod\" type=\"text\"/> \t\t<field name=\"accountNumberField1\" key=\"part1\" type=\"text\"/> \t\t<field name=\"accountNumberField2\" key=\"part2\" type=\"text\"/> \t\t<field name=\"accountNumberField3\" key=\"part3\" type=\"text\"/> \t\t<field name=\"accountNumberField4\" key=\"part4\" type=\"text\"/> \t\t<field name=\"accountNumberField5\" key=\"part5\" type=\"text\"/> \t\t<field name=\"PartyEmailAddress\" key=\"partyEmail\" type=\"text\"/> \t\t<field name=\"phone_number\" key=\"payersTelephoneNumber\" type=\"text\"/> \t\t<field name=\"payers_full_name\" key=\"partyGivenName\" type=\"text\"/> \t\t<field name=\"custom_field_2\" key=\"custom_field_2\" type=\"text\"/> \t\t<field name=\"custom_field_3\" key=\"custom_field_3\" type=\"text\"/> \t\t<field name=\"PaymentMethodMethodCode\" key=\"PaymentMethodMethodCode\" type=\"text\"/> \t\t<field name=\"custom_field_1\" key=\"custom_field_1\" type=\"text\"/> \t\t<field name=\"PaygovCollection\" key=\"PaygovCollection\" type=\"text\"/> \t\t<field name=\"PostalCountry\" key=\"partyCountry\" type=\"text\"/> \t\t<field name=\"PartyGivenNameText\" key=\"partyGivenName\" type=\"text\"/> \t</subform> </form>"},"settings":{"hideTitle":true},"access":[{"roles":["5f9ae327f1b65926a66350f3","5f9ae327f1b65921a76350f4"],"type":"read_all"},{"roles":["5f9ae327f1b65926a66350f3"],"type":"update_all"}],"submissionAccess":[{"roles":["5f9ae327f1b65926a66350f3","5f9ae327f1b65921a76350f4"],"type":"create_all"}],"project":"5f9ae327f1b65987a86350f2","created":"2021-01-07T19:10:03.029Z","modified":"2024-07-12T20:12:36.652Z","_rid":"5ff75c8bcfd076f8b7060dd4","config":{"PAYGOV_ENV":"https://www.pay.gov","STATIC_ASSETS_ENV":"https://www.pay.gov/public/static-assets/paygov","COMPANY_PROFILE":"public/api/v1/companyprofile","MIN_MAX_AMOUNT":"public/api/v1/minmaxamount","GET_COUNTRIES":"public/api/v1/getCountries","GET_STATES":"public/api/v1/getStates"},"module":"{options:{form:{evalContext:{pgFormioGlobal:function(){function o(a,e,t,o){if(a=a&&a.replace(e,\"\")){if(t)return t;t=(o||\"Input\")+\" contains invalid \";e=a.replace(/[\\x00-\\x20\\x7F]/g,\"\");return 1===e.length?t+=e+\" \":1<e.length&&(t+=e.split(\"\").join(\" \")+\" \"),a.length>e.length&&((o=a.replace(/[^ ]/g,\"\")).length?a.length===e.length+o.length?t+=e.length?\"and space \":\"space \":t+=\"space and non-printable \":t+=e.length?\"and non-printable \":\"non-printable \"),t+\"character\"+(1<a.length?\"s.\":\".\")}return!0}return{countries:function(){return[{alpha3Code:\"USA\",countryName:\"United States\"},{alpha3Code:\"CAN\",countryName:\"Canada\"},{alpha3Code:\"AFG\",countryName:\"Afghanistan\"},{alpha3Code:\"ALA\",countryName:\"Aland Islands\"},{alpha3Code:\"ALB\",countryName:\"Albania\"},{alpha3Code:\"DZA\",countryName:\"Algeria\"},{alpha3Code:\"ASM\",countryName:\"American Samoa\"},{alpha3Code:\"AND\",countryName:\"Andorra\"},{alpha3Code:\"AGO\",countryName:\"Angola\"},{alpha3Code:\"AIA\",countryName:\"Anguilla\"},{alpha3Code:\"ATG\",countryName:\"Antigua and Barbuda\"},{alpha3Code:\"ARG\",countryName:\"Argentina\"},{alpha3Code:\"ARM\",countryName:\"Armenia\"},{alpha3Code:\"ABW\",countryName:\"Aruba\"},{alpha3Code:\"AUS\",countryName:\"Australia\"},{alpha3Code:\"AUT\",countryName:\"Austria\"},{alpha3Code:\"AZE\",countryName:\"Azerbaijan\"},{alpha3Code:\"BHS\",countryName:\"Bahamas\"},{alpha3Code:\"BHR\",countryName:\"Bahrain\"},{alpha3Code:\"BGD\",countryName:\"Bangladesh\"},{alpha3Code:\"BRB\",countryName:\"Barbados\"},{alpha3Code:\"BLR\",countryName:\"Belarus\"},{alpha3Code:\"BEL\",countryName:\"Belgium\"},{alpha3Code:\"BLZ\",countryName:\"Belize\"},{alpha3Code:\"BEN\",countryName:\"Benin\"},{alpha3Code:\"BMU\",countryName:\"Bermuda\"},{alpha3Code:\"BTN\",countryName:\"Bhutan\"},{alpha3Code:\"BOL\",countryName:\"Bolivia\"},{alpha3Code:\"BES\",countryName:\"Bonaire and Sint Eustatius and Saba\"},{alpha3Code:\"BIH\",countryName:\"Bosnia and Herzegovina\"},{alpha3Code:\"BWA\",countryName:\"Botswana\"},{alpha3Code:\"BRA\",countryName:\"Brazil\"},{alpha3Code:\"VGB\",countryName:\"British Virgin Islands\"},{alpha3Code:\"BRN\",countryName:\"Brunei Darussalam\"},{alpha3Code:\"BGR\",countryName:\"Bulgaria\"},{alpha3Code:\"BFA\",countryName:\"Burkina Faso\"},{alpha3Code:\"BDI\",countryName:\"Burundi\"},{alpha3Code:\"KHM\",countryName:\"Cambodia\"},{alpha3Code:\"CMR\",countryName:\"Cameroon\"},{alpha3Code:\"CPV\",countryName:\"Cape Verde\"},{alpha3Code:\"CYM\",countryName:\"Cayman Islands\"},{alpha3Code:\"CAF\",countryName:\"Central African Republic\"},{alpha3Code:\"TCD\",countryName:\"Chad\"},{alpha3Code:\"CHL\",countryName:\"Chile\"},{alpha3Code:\"CHN\",countryName:\"China\"},{alpha3Code:\"COL\",countryName:\"Colombia\"},{alpha3Code:\"COM\",countryName:\"Comoros\"},{alpha3Code:\"COG\",countryName:\"Congo\"},{alpha3Code:\"COD\",countryName:\"Congo Democratic Republic\"},{alpha3Code:\"COK\",countryName:\"Cook Islands\"},{alpha3Code:\"CRI\",countryName:\"Costa Rica\"},{alpha3Code:\"CIV\",countryName:\"Cote d'Ivoire\"},{alpha3Code:\"HRV\",countryName:\"Croatia\"},{alpha3Code:\"CUB\",countryName:\"Cuba\"},{alpha3Code:\"CUW\",countryName:\"Curacao\"},{alpha3Code:\"CYP\",countryName:\"Cyprus\"},{alpha3Code:\"CZE\",countryName:\"Czech Republic\"},{alpha3Code:\"DNK\",countryName:\"Denmark\"},{alpha3Code:\"DJI\",countryName:\"Djibouti\"},{alpha3Code:\"DMA\",countryName:\"Dominica\"},{alpha3Code:\"DOM\",countryName:\"Dominican Republic\"},{alpha3Code:\"ECU\",countryName:\"Ecuador\"},{alpha3Code:\"EGY\",countryName:\"Egypt\"},{alpha3Code:\"SLV\",countryName:\"El Salvador\"},{alpha3Code:\"GNQ\",countryName:\"Equatorial Guinea\"},{alpha3Code:\"ERI\",countryName:\"Eritrea\"},{alpha3Code:\"EST\",countryName:\"Estonia\"},{alpha3Code:\"ETH\",countryName:\"Ethiopia\"},{alpha3Code:\"FLK\",countryName:\"Falkland Islands\"},{alpha3Code:\"FRO\",countryName:\"Faroe Islands\"},{alpha3Code:\"FJI\",countryName:\"Fiji\"},{alpha3Code:\"FIN\",countryName:\"Finland\"},{alpha3Code:\"FRA\",countryName:\"France\"},{alpha3Code:\"GUF\",countryName:\"French Guiana\"},{alpha3Code:\"PYF\",countryName:\"French Polynesia\"},{alpha3Code:\"GAB\",countryName:\"Gabon\"},{alpha3Code:\"GMB\",countryName:\"Gambia\"},{alpha3Code:\"GEO\",countryName:\"Georgia\"},{alpha3Code:\"DEU\",countryName:\"Germany\"},{alpha3Code:\"GHA\",countryName:\"Ghana\"},{alpha3Code:\"GIB\",countryName:\"Gibraltar\"},{alpha3Code:\"GRC\",countryName:\"Greece\"},{alpha3Code:\"GRL\",countryName:\"Greenland\"},{alpha3Code:\"GRD\",countryName:\"Grenada\"},{alpha3Code:\"GLP\",countryName:\"Guadeloupe\"},{alpha3Code:\"GUM\",countryName:\"Guam\"},{alpha3Code:\"GTM\",countryName:\"Guatemala\"},{alpha3Code:\"GGY\",countryName:\"Guernsey\"},{alpha3Code:\"GIN\",countryName:\"Guinea\"},{alpha3Code:\"GNB\",countryName:\"Guinea Bissau\"},{alpha3Code:\"GUY\",countryName:\"Guyana\"},{alpha3Code:\"HTI\",countryName:\"Haiti\"},{alpha3Code:\"VAT\",countryName:\"Holy See Vatican City\"},{alpha3Code:\"HND\",countryName:\"Honduras\"},{alpha3Code:\"HKG\",countryName:\"Hong Kong\"},{alpha3Code:\"HUN\",countryName:\"Hungary\"},{alpha3Code:\"ISL\",countryName:\"Iceland\"},{alpha3Code:\"IND\",countryName:\"India\"},{alpha3Code:\"IDN\",countryName:\"Indonesia\"},{alpha3Code:\"IRQ\",countryName:\"Iraq\"},{alpha3Code:\"IRL\",countryName:\"Ireland\"},{alpha3Code:\"IMN\",countryName:\"Isle of Man\"},{alpha3Code:\"ISR\",countryName:\"Israel\"},{alpha3Code:\"ITA\",countryName:\"Italy\"},{alpha3Code:\"JAM\",countryName:\"Jamaica\"},{alpha3Code:\"JPN\",countryName:\"Japan\"},{alpha3Code:\"JEY\",countryName:\"Jersey\"},{alpha3Code:\"JOR\",countryName:\"Jordan\"},{alpha3Code:\"KAZ\",countryName:\"Kazakhstan\"},{alpha3Code:\"KEN\",countryName:\"Kenya\"},{alpha3Code:\"KIR\",countryName:\"Kiribati\"},{alpha3Code:\"PRK\",countryName:\"Korea Democratic Peoples Republic\"},{alpha3Code:\"KOR\",countryName:\"Korea Republic\"},{alpha3Code:\"QZZ\",countryName:\"Kosovo\"},{alpha3Code:\"KWT\",countryName:\"Kuwait\"},{alpha3Code:\"KGZ\",countryName:\"Kyrgyzstan\"},{alpha3Code:\"LAO\",countryName:\"Lao People's Democratic Republic\"},{alpha3Code:\"LVA\",countryName:\"Latvia\"},{alpha3Code:\"LBN\",countryName:\"Lebanon\"},{alpha3Code:\"LSO\",countryName:\"Lesotho\"},{alpha3Code:\"LBR\",countryName:\"Liberia\"},{alpha3Code:\"LBY\",countryName:\"Libya\"},{alpha3Code:\"LIE\",countryName:\"Liechtenstein\"},{alpha3Code:\"LTU\",countryName:\"Lithuania\"},{alpha3Code:\"LUX\",countryName:\"Luxembourg\"},{alpha3Code:\"MAC\",countryName:\"Macao\"},{alpha3Code:\"MKD\",countryName:\"Macedonia\"},{alpha3Code:\"MDG\",countryName:\"Madagascar\"},{alpha3Code:\"MWI\",countryName:\"Malawi\"},{alpha3Code:\"MYS\",countryName:\"Malaysia\"},{alpha3Code:\"MDV\",countryName:\"Maldives\"},{alpha3Code:\"MLI\",countryName:\"Mali\"},{alpha3Code:\"MLT\",countryName:\"Malta\"},{alpha3Code:\"MHL\",countryName:\"Marshall Islands\"},{alpha3Code:\"MTQ\",countryName:\"Martinique\"},{alpha3Code:\"MRT\",countryName:\"Mauritania\"},{alpha3Code:\"MUS\",countryName:\"Mauritius\"},{alpha3Code:\"SJM\",countryName:\"Mayen Islands\"},{alpha3Code:\"MYT\",countryName:\"Mayotte\"},{alpha3Code:\"MEX\",countryName:\"Mexico\"},{alpha3Code:\"FSM\",countryName:\"Micronesia Federated States\"},{alpha3Code:\"MDA\",countryName:\"Moldova\"},{alpha3Code:\"MCO\",countryName:\"Monaco\"},{alpha3Code:\"MNG\",countryName:\"Mongolia\"},{alpha3Code:\"MNE\",countryName:\"Montenegro\"},{alpha3Code:\"MSR\",countryName:\"Montserrat\"},{alpha3Code:\"MAR\",countryName:\"Morocco\"},{alpha3Code:\"MOZ\",countryName:\"Mozambique\"},{alpha3Code:\"MMR\",countryName:\"Myanmar\"},{alpha3Code:\"NAM\",countryName:\"Namibia\"},{alpha3Code:\"NRU\",countryName:\"Nauru\"},{alpha3Code:\"NPL\",countryName:\"Nepal\"},{alpha3Code:\"NLD\",countryName:\"Netherlands\"},{alpha3Code:\"ANT\",countryName:\"Netherlands Antilles\"},{alpha3Code:\"NCL\",countryName:\"New Caledonia\"},{alpha3Code:\"NZL\",countryName:\"New Zealand\"},{alpha3Code:\"NIC\",countryName:\"Nicaragua\"},{alpha3Code:\"NER\",countryName:\"Niger\"},{alpha3Code:\"NGA\",countryName:\"Nigeria\"},{alpha3Code:\"NIU\",countryName:\"Niue\"},{alpha3Code:\"NFK\",countryName:\"Norfolk Island\"},{alpha3Code:\"MNP\",countryName:\"Northern Mariana Islands\"},{alpha3Code:\"NOR\",countryName:\"Norway\"},{alpha3Code:\"OMN\",countryName:\"Oman\"},{alpha3Code:\"PAK\",countryName:\"Pakistan\"},{alpha3Code:\"PLW\",countryName:\"Palau\"},{alpha3Code:\"PSE\",countryName:\"Palestinian Territory\"},{alpha3Code:\"PAN\",countryName:\"Panama\"},{alpha3Code:\"PNG\",countryName:\"Papua New Guinea\"},{alpha3Code:\"PRY\",countryName:\"Paraguay\"},{alpha3Code:\"PER\",countryName:\"Peru\"},{alpha3Code:\"PHL\",countryName:\"Philippines\"},{alpha3Code:\"PCN\",countryName:\"Pitcairn\"},{alpha3Code:\"POL\",countryName:\"Poland\"},{alpha3Code:\"PRT\",countryName:\"Portugal\"},{alpha3Code:\"PRI\",countryName:\"Puerto Rico\"},{alpha3Code:\"QAT\",countryName:\"Qatar\"},{alpha3Code:\"REU\",countryName:\"Reunion\"},{alpha3Code:\"ROU\",countryName:\"Romania\"},{alpha3Code:\"RUS\",countryName:\"Russian Federation\"},{alpha3Code:\"RWA\",countryName:\"Rwanda\"},{alpha3Code:\"BLM\",countryName:\"Saint Barthelemy\"},{alpha3Code:\"SHN\",countryName:\"Saint Helena\"},{alpha3Code:\"KNA\",countryName:\"Saint Kitts and Nevis\"},{alpha3Code:\"LCA\",countryName:\"Saint Lucia\"},{alpha3Code:\"MAF\",countryName:\"Saint Martin\"},{alpha3Code:\"SPM\",countryName:\"Saint Pierre and Miquelon\"},{alpha3Code:\"VCT\",countryName:\"Saint Vincent and the Grenadines\"},{alpha3Code:\"WSM\",countryName:\"Samoa\"},{alpha3Code:\"SMR\",countryName:\"San Marino\"},{alpha3Code:\"STP\",countryName:\"Sao Tome and Principe\"},{alpha3Code:\"SAU\",countryName:\"Saudi Arabia\"},{alpha3Code:\"SEN\",countryName:\"Senegal\"},{alpha3Code:\"SRB\",countryName:\"Serbia\"},{alpha3Code:\"SYC\",countryName:\"Seychelles\"},{alpha3Code:\"SLE\",countryName:\"Sierra Leone\"},{alpha3Code:\"SGP\",countryName:\"Singapore\"},{alpha3Code:\"SXM\",countryName:\"Sint Maarten Dutch Part\"},{alpha3Code:\"SVK\",countryName:\"Slovakia\"},{alpha3Code:\"SVN\",countryName:\"Slovenia\"},{alpha3Code:\"SLB\",countryName:\"Solomon Islands\"},{alpha3Code:\"SOM\",countryName:\"Somalia\"},{alpha3Code:\"ZAF\",countryName:\"South Africa\"},{alpha3Code:\"ESP\",countryName:\"Spain\"},{alpha3Code:\"LKA\",countryName:\"Sri Lanka\"},{alpha3Code:\"SUR\",countryName:\"Suriname\"},{alpha3Code:\"SWZ\",countryName:\"Swaziland\"},{alpha3Code:\"SWE\",countryName:\"Sweden\"},{alpha3Code:\"CHE\",countryName:\"Switzerland\"},{alpha3Code:\"SYR\",countryName:\"Syrian Arab Republic\"},{alpha3Code:\"TWN\",countryName:\"Taiwan\"},{alpha3Code:\"TJK\",countryName:\"Tajikistan\"},{alpha3Code:\"TZA\",countryName:\"Tanzania\"},{alpha3Code:\"THA\",countryName:\"Thailand\"},{alpha3Code:\"TLS\",countryName:\"Timor Leste\"},{alpha3Code:\"TGO\",countryName:\"Togo\"},{alpha3Code:\"TKL\",countryName:\"Tokelau\"},{alpha3Code:\"TON\",countryName:\"Tonga\"},{alpha3Code:\"TTO\",countryName:\"Trinidad and Tobago\"},{alpha3Code:\"TUN\",countryName:\"Tunisia\"},{alpha3Code:\"TUR\",countryName:\"Turkey\"},{alpha3Code:\"TKM\",countryName:\"Turkmenistan\"},{alpha3Code:\"TCA\",countryName:\"Turks and Caicos Islands\"},{alpha3Code:\"TUV\",countryName:\"Tuvalu\"},{alpha3Code:\"UGA\",countryName:\"Uganda\"},{alpha3Code:\"UKR\",countryName:\"Ukraine\"},{alpha3Code:\"ARE\",countryName:\"United Arab Emirates\"},{alpha3Code:\"GBR\",countryName:\"United Kingdom\"},{alpha3Code:\"URY\",countryName:\"Uruguay\"},{alpha3Code:\"UZB\",countryName:\"Uzbekistan\"},{alpha3Code:\"VUT\",countryName:\"Vanuatu\"},{alpha3Code:\"VEN\",countryName:\"Venezuela\"},{alpha3Code:\"VNM\",countryName:\"Vietnam\"},{alpha3Code:\"VIR\",countryName:\"Virgin Islands, US\"},{alpha3Code:\"WLF\",countryName:\"Wallis and Futuna Islands\"},{alpha3Code:\"ESH\",countryName:\"Western Sahara\"},{alpha3Code:\"YEM\",countryName:\"Yemen\"},{alpha3Code:\"ZMB\",countryName:\"Zambia\"},{alpha3Code:\"ZWE\",countryName:\"Zimbabwe\"}]},states:function(){return{USA:[{stateAbbreviation:\"AL\",stateName:\"Alabama\"},{stateAbbreviation:\"AK\",stateName:\"Alaska\"},{stateAbbreviation:\"AS\",stateName:\"American Samoa\"},{stateAbbreviation:\"AZ\",stateName:\"Arizona\"},{stateAbbreviation:\"AR\",stateName:\"Arkansas\"},{stateAbbreviation:\"CA\",stateName:\"California\"},{stateAbbreviation:\"CO\",stateName:\"Colorado\"},{stateAbbreviation:\"CT\",stateName:\"Connecticut\"},{stateAbbreviation:\"DE\",stateName:\"Delaware\"},{stateAbbreviation:\"DC\",stateName:\"District Of Columbia\"},{stateAbbreviation:\"FM\",stateName:\"Federated States of Micronesia\"},{stateAbbreviation:\"FL\",stateName:\"Florida\"},{stateAbbreviation:\"GA\",stateName:\"Georgia\"},{stateAbbreviation:\"GU\",stateName:\"Guam\"},{stateAbbreviation:\"HI\",stateName:\"Hawaii\"},{stateAbbreviation:\"ID\",stateName:\"Idaho\"},{stateAbbreviation:\"IL\",stateName:\"Illinois\"},{stateAbbreviation:\"IN\",stateName:\"Indiana\"},{stateAbbreviation:\"IA\",stateName:\"Iowa\"},{stateAbbreviation:\"KS\",stateName:\"Kansas\"},{stateAbbreviation:\"KY\",stateName:\"Kentucky\"},{stateAbbreviation:\"LA\",stateName:\"Louisiana\"},{stateAbbreviation:\"ME\",stateName:\"Maine\"},{stateAbbreviation:\"MH\",stateName:\"Marshall Islands\"},{stateAbbreviation:\"MD\",stateName:\"Maryland\"},{stateAbbreviation:\"MA\",stateName:\"Massachusetts\"},{stateAbbreviation:\"MI\",stateName:\"Michigan\"},{stateAbbreviation:\"AA\",stateName:\"Military Americas\"},{stateAbbreviation:\"AE\",stateName:\"Military East\"},{stateAbbreviation:\"AP\",stateName:\"Military Pacific\"},{stateAbbreviation:\"MN\",stateName:\"Minnesota\"},{stateAbbreviation:\"MS\",stateName:\"Mississippi\"},{stateAbbreviation:\"MO\",stateName:\"Missouri\"},{stateAbbreviation:\"MT\",stateName:\"Montana\"},{stateAbbreviation:\"NE\",stateName:\"Nebraska\"},{stateAbbreviation:\"NV\",stateName:\"Nevada\"},{stateAbbreviation:\"NH\",stateName:\"New Hampshire\"},{stateAbbreviation:\"NJ\",stateName:\"New Jersey\"},{stateAbbreviation:\"NM\",stateName:\"New Mexico\"},{stateAbbreviation:\"NY\",stateName:\"New York\"},{stateAbbreviation:\"NC\",stateName:\"North Carolina\"},{stateAbbreviation:\"ND\",stateName:\"North Dakota\"},{stateAbbreviation:\"MP\",stateName:\"Northern Mariana Islands\"},{stateAbbreviation:\"OH\",stateName:\"Ohio\"},{stateAbbreviation:\"OK\",stateName:\"Oklahoma\"},{stateAbbreviation:\"OR\",stateName:\"Oregon\"},{stateAbbreviation:\"PW\",stateName:\"Palau\"},{stateAbbreviation:\"PA\",stateName:\"Pennsylvania\"},{stateAbbreviation:\"PR\",stateName:\"Puerto Rico\"},{stateAbbreviation:\"RI\",stateName:\"Rhode Island\"},{stateAbbreviation:\"SC\",stateName:\"South Carolina\"},{stateAbbreviation:\"SD\",stateName:\"South Dakota\"},{stateAbbreviation:\"TN\",stateName:\"Tennessee\"},{stateAbbreviation:\"TX\",stateName:\"Texas\"},{stateAbbreviation:\"UT\",stateName:\"Utah\"},{stateAbbreviation:\"UM\",stateName:\"U.S. Minor Outlying Islands\"},{stateAbbreviation:\"VT\",stateName:\"Vermont\"},{stateAbbreviation:\"VI\",stateName:\"Virgin Islands of the U.S.\"},{stateAbbreviation:\"VA\",stateName:\"Virginia\"},{stateAbbreviation:\"WA\",stateName:\"Washington\"},{stateAbbreviation:\"WV\",stateName:\"West Virginia\"},{stateAbbreviation:\"WI\",stateName:\"Wisconsin\"},{stateAbbreviation:\"WY\",stateName:\"Wyoming\"}],CAN:[{stateAbbreviation:\"AB\",stateName:\"Alberta\"},{stateAbbreviation:\"BC\",stateName:\"British Columbia\"},{stateAbbreviation:\"MB\",stateName:\"Manitoba\"},{stateAbbreviation:\"NB\",stateName:\"New Brunswick\"},{stateAbbreviation:\"NL\",stateName:\"Newfoundland and Labrador\"},{stateAbbreviation:\"NS\",stateName:\"Nova Scotia\"},{stateAbbreviation:\"NT\",stateName:\"Northwest Territories\"},{stateAbbreviation:\"NU\",stateName:\"Nunavut\"},{stateAbbreviation:\"ON\",stateName:\"Ontario\"},{stateAbbreviation:\"PE\",stateName:\"Prince Edward Island\"},{stateAbbreviation:\"QC\",stateName:\"Quebec\"},{stateAbbreviation:\"SK\",stateName:\"Saskatchewan\"},{stateAbbreviation:\"YT\",stateName:\"Yukon\"}]}},validateText:function(a,e,t){return o(a,/[-a-zA-Z0-9_ \\$'\\(\\),\\.@\\|&:/]/g,e,t)},validateTextArea:function(a,e,t){return o(a,/[-a-zA-Z0-9_ \\$'\\(\\),\\.@\\|&:/\\r\\n\\t]/g,e,t)},validateEmail:function(a,e,t){return!a||(!0!==(e=o(a,/[-a-zA-Z0-9#\\$&'\\*\\+/=\\?\\^_`\\{\\|\\}~@\\.]/g,e,t||\"Email\"))?e:a.length<6?\"Email must have at least 6 characters.\":70<a.length?\"Email must not have more than 70 characters.\":!!/^[-a-zA-Z0-9#\\$&'\\*\\+/=\\?\\^_`\\{\\|\\}~]+(?:\\.[-a-zA-Z0-9#\\$&'\\*\\+/=\\?\\^_`\\{\\|\\}~]+)*@(?:[a-zA-Z0-9](?:[a-zA-Z0-9-]*[a-zA-Z0-9])?\\.)+[a-zA-Z0-9](?:[a-zA-Z0-9-]*[a-zA-Z0-9])?$/.test(a)||\"Email must be valid.\")},validateMinMax:function(a,e,t){if(a){if(!(0<=a))return\"Input must be a valid dollar amount.\";e=e.minMax||t.config.minMax;if(a<parseFloat(e.minAmount))return\"Your payment is below the allowed amount. Please enter a higher dollar amount.\";if(a>parseFloat(e.maxAmount))return\"Your payment is above the maximum allowed amount. Please enter a lower dollar amount.\"}return!0}}}}}}}"}