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add keys for 10-10ez pdf fill (#20852)
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@coope93
coope93 authored Feb 20, 2025
1 parent cd6d39e commit 9a71ac4
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291 changes: 291 additions & 0 deletions lib/pdf_fill/forms/va1010ez.rb
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Original file line number Diff line number Diff line change
Expand Up @@ -10,6 +10,297 @@ class Va1010ez < FormBase
KEY = {
'veteranFullName' => {
key: 'F[0].P4[0].LastFirstMiddle[0]'
},
'mothersMaidenName' => {
key: 'F[0].P4[0].MothersMaidenName[0]'
},
'gender' => {
key: 'F[0].P4[0].BirthSex[0]'
},
'isSpanishHispanicLatino' => {
key: 'F[0].P4[0].HispanicOrLatino[0]'
},
'isAmericanIndianOrAlaskanNative' => {
key: 'F[0].P4[0].Race[0]'
},
'isAsian' => {
key: 'F[0].P4[0].Race[1]'
},
'isWhite' => {
key: 'F[0].P4[0].Race[2]'
},
'isBlackOrAfricanAmerican' => {
key: 'F[0].P4[0].Race[3]'
},
'isNativeHawaiianOrOtherPacificIslander' => {
key: 'F[0].P4[0].Race[4]'
},
'hasDemographicNoAnswer' => {
key: 'F[0].P4[0].Race[5]'
},
'placeOfBirth' => {
key: 'F[0].P4[0].PlaceOfBirth[0]'
},
'veteranAddress' =>
{
'street' => {
key: 'F[0].P4[0].MailingAddress_Street[0]'
},
'city' => {
key: 'F[0].P4[0].MailingAddress_City[0]'
},
'postalCode' => {
key: 'F[0].P4[0].MailingAddress_ZipCode[0]'
},
'state' => {
key: 'F[0].P4[0].MailingAddress_State[0]'
}
},
'homePhone' => {
key: 'F[0].P4[0].HomeTelephoneNumber[0]'
},
'mobilePhone' => {
key: 'F[0].P4[0].MbileTelephoneNumber[0]'
},
'email' => {
key: 'F[0].P4[0].EmailAddress[0]'
},
'veteranHomeAddress' =>
{
'street' => {
key: 'F[0].P4[0].HomeAddress_Street[0]'
},
'city' => {
key: 'F[0].P4[0].HomeAddress_City[0]'
},
'postalCode' => {
key: 'F[0].P4[0].HomeAddress_ZipCode[0]'
},
'state' => {
key: 'F[0].P4[0].HomeAddress_State[0]'
}
},
'maritalStatus' => {
key: 'F[0].P4[0].CurrentMaritalStatus[0]'
},
'vaMedicalFacility' => {
key: 'F[0].P4[0].PreferredVACenter[0]'
},
'wantsInitialVaContact' => {
key: 'F[0].P4[0].ScheduleFirstAppointment[0]'
},
'purpleHeartRecipient' => {
key: 'F[0].P4[0].Section2_2A[0]'
},
'isFormerPow' => {
key: 'F[0].P4[0].Section2_2B[0]'
},
'postNov111998Combat' => {
key: 'F[0].P4[0].Section2_2C[0]'
},
'disabledInLineOfDuty' => {
key: 'F[0].P4[0].Section2_2D[0]'
},
'swAsiaCombat' => {
key: 'F[0].P4[0].Section2_2E[0]'
},
'vaCompensationType' => {
key: 'F[0].P4[0].Section2_2F[0]'
},
'radiationCleanupEfforts' => {
key: 'F[0].P5[0].RadioButtonList[2]'
},
'gulfWarService' => {
key: 'F[0].P5[0].RadioButtonList[3]'
},
'combatOperationService' => {
key: 'F[0].P5[0].RadioButtonList[0]'
},
'exposedToAgentOrange' => {
key: 'F[0].P5[0].RadioButtonList[1]'
},
'gulfWarStartDate' => {
key: 'F[0].P5[0].FromDate_3B[0]'
},
'gulfWarEndDate' => {
key: 'F[0].P5[0].ToDate_3B[0]'
},
'agentOrangeStartDate' => {
key: 'F[0].P5[0].FromDate_3C[0]'
},
'agentOrangeEndDate' => {
key: 'F[0].P5[0].ToDate_3C[0]'
},
'exposureToAirPollutants' => {
key: 'F[0].P5[0].ExposedToTheFollowing[0]'
},
'exposureToChemicals' => {
key: 'F[0].P5[0].ExposedToTheFollowing[1]'
},
'exposureToRadiation' => {
key: 'F[0].P5[0].ExposedToTheFollowing[2]'
},
'exposureToShad' => {
key: 'F[0].P5[0].ExposedToTheFollowing[3]'
},
'exposureToOccupationalHazards' => {
key: 'F[0].P5[0].ExposedToTheFollowing[4]'
},
'exposureToAsbestos' => {
key: 'F[0].P5[0].ExposedToTheFollowing[5]'
},
'exposureToMustardGas' => {
key: 'F[0].P5[0].ExposedToTheFollowing[6]'
},
'exposureToContaminatedWater' => {
key: 'F[0].P5[0].ExposedToTheFollowing[7]'
},
'exposureToWarfareAgents' => {
key: 'F[0].P5[0].ExposedToTheFollowing[8]'
},
'exposureToOther' => {
key: 'F[0].P5[0].ExposedToTheFollowing[9]'
},
'otherToxicExposure' => {
key: 'F[0].P5[0].SpecifyOther[0]'
},
'toxicExposureStartDate' => {
key: 'F[0].P5[0].FromDate_3D[0]'
},
'toxicExposureEndDate' => {
key: 'F[0].P5[0].ToDate_3D[0]'
},
'isMedicaidEligible' => {
key: 'F[0].P5[0].EligibleForMedicaid[0]'
},
'isEnrolledMedicarePartA' => {
key: 'F[0].P5[0].EnrolledInMedicareHospitalInsurance[0]'
},
'providers' =>
{
'insuranceName' => {
key: 'F[0].P5[0].HealthInsuranceInformation[0]'
},
'insurancePolicyHolderName' => {
key: 'F[0].P5[0].NameOfPolicyHodler[0]'
},
'insurancePolicyNumber' => {
key: 'F[0].P5[0].PolicyNumber[0]'
},
'insuranceGroupCode' => {
key: 'F[0].P5[0].GroupCode[0]'
}
},
'dependents' =>
{
'fullName' => {
key: 'F[0].P5[0].ChildsName[0]'
},
'dependentRelation' => {
key: 'F[0].P5[0].RelationshipToYou[0]'
},
'socialSecurityNumber' => {
key: 'F[0].P5[0].ChildsSSN[0]'
},
'dateOfBirth' => {
key: 'F[0].P5[0].ChildsDOB[0]'
},
'becameDependent' => {
key: 'F[0].P5[0].DateChildBecameYourDependent[0]'
},
'attendedSchoolLastYear' => {
key: 'F[0].P5[0].DidChildAttendSchooLastYear[0]'
},
'disabledBefore18' => {
key: 'F[0].P5[0].ChildPermanentlyDiasbledBefore18[0]'
},
'dependentEducationExpenses' => {
key: 'F[0].P5[0].ExpensesPaifByDependentCHild[0]'
},
'grossIncome' => {
key: 'F[0].P6[0].Section7_Child_Q1[0]'
},
'netIncome' => {
key: 'F[0].P6[0].Section7_Child_Q2[0]'
},
'otherIncome' => {
key: 'F[0].P6[0].Section7_Child_Q3[0]'
}
},
'spouseFullName' => {
key: 'F[0].P5[0].SpousesName[0]'
},
'spouseAddress' => {
key: 'F[0].P5[0].SpouseAddressAndTelephoneNumber[0]'
},
'cohabitedLastYear' => {
key: 'F[0].P5[0].RadioButtonList[2]'
},
'veteranDateOfBirth' => {
key: 'F[0].P4[0].DOB[0]'
},
'lastEntryDate' => {
key: 'F[0].P4[0].LastEntryDate[0]'
},
'lastDischargeDate' => {
key: 'F[0].P4[0].LastDischargeDate[0]'
},
'medicarePartAEffectiveDate' => {
key: 'F[0].P5[0].EffectiveDate[0]'
},
'spouseSocialSecurityNumber' => {
key: 'F[0].P5[0].SpousesSSN[0]'
},
'spouseDateOfBirth' => {
key: 'F[0].P5[0].SpousesDOB[0]'
},
'dateOfMarriage' => {
key: 'F[0].P5[0].DateOfMarriage[0]'
},
'provideSupportLastYear' => {
key: 'F[0].P5[0].DidYouProvideSupportToChildNotLivingWithYou[0]'
},
'discloseFinancialInformation' => {
key: 'F[0].P6[0].Section6[0]'
},
'veteranSocialSecurityNumber' => {
key: 'F[0].P4[0].SSN[0]'
},
'lastServiceBranch' => {
key: 'F[0].P4[0].LastBranchOfService[0]'
},
'dischargeType' => {
key: 'F[0].P4[0].DischargeType[0]'
},
'medicareClaimNumber' => {
key: 'F[0].P5[0].MedicareClaimNumber[0]'
},
'spouseGrossIncome' => {
key: 'F[0].P6[0].Section7_Spouse_Q1[0]'
},
'spouseNetIncome' => {
key: 'F[0].P6[0].Section7_Spouse_Q2[0]'
},
'spouseOtherIncome' => {
key: 'F[0].P6[0].Section7_Spouse_Q3[0]'
},
'veteranGrossIncome' => {
key: 'F[0].P6[0].Section7_Veteran_Q1[0]'
},
'veteranNetIncome' => {
key: 'F[0].P6[0].Section7_Veteran_Q2[0]'
},
'veteranOtherIncome' => {
key: 'F[0].P6[0].Section7_Veteran_Q3[0]'
},
'deductibleMedicalExpenses' => {
key: 'F[0].P6[0].Section8_Q1[0]'
},
'deductibleFuneralExpenses' => {
key: 'F[0].P6[0].Section8_Q2[0]'
},
'deductibleEducationExpenses' => {
key: 'F[0].P6[0].Section8_Q3[0]'
}
}.freeze

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