software/old_dependents.html at master · swoleengineer/software · GitHub

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												<div class="clearfix">
													<label class="col-md-2">First Name</label>
													<label class="col-md-3">Last Name</label>
													<label class="col-md-1">DOB</label>
													<label class="col-md-2">SSN</label>
													<label class="col-md-2">Relationship</label>
													<label class="col-md-1">Mo</label>
													<label class="col-md-1" title="(E)ligible, (S)tudent, (D)isabled, (K)idnapped, (N)one" data-toggle="tooltip">Code</label>
												</div>
												<div class="clearfix formGroup stackedInputs">
													<input class="col-md-2" type="text" placeholder="First Name"  >
													<input class="col-md-3" type="text" placeholder="Last Name"  >
													<input class="col-md-1" type="text" placeholder="DOB"  >
													<input class="col-md-2" type="text" placeholder="SSN"  >
													<select class="col-md-2" id="tpMarital" name=""  title="Relationship">
															<option value="0" selected="selected">Relationship</option>
															<option value="son">Son</option>
															<option value="daughter">Daughter</option>
															<option value="stepchild">Stepchild</option>
															<option value="halfBrother">Half Brother</option>
															<option value="halfSister">Half Sister</option>
															<option value="stepBrother">Step Brother</option>
															<option value="stepSister">Step Sister</option>
															<option value="fosterChild">Foster Child</option>
															<option value="nephew">Nephew</option>
															<option value="niece">Niece</option>
															<option value="grandchild">Grand Child</option>
															<option value="grandparent">Grand Parent</option>
															<option value="parent">Parent</option>
															<option value="brother">Brother</option>
															<option value="sister">Sister</option>
															<option value="aunt">Aunt</option>
															<option value="uncle">Uncle</option>
															<option value="none">None</option>
															<option value="other">Other</option>
													</select>
													<input class="col-md-1" type="text" placeholder="Mo"  >
													<input class="col-md-1" title="(E)ligible, (S)tudent, (D)isabled, (K)idnapped, (N)one" data-toggle="tooltip" placeholder="Code"  >
												</div>
												<div class="clearfix formGroup stackedInputs">
													<input class="col-md-2" type="text" placeholder="First Name"  >
													<input class="col-md-3" type="text" placeholder="Last Name"  >
													<input class="col-md-1" type="text" placeholder="DOB"  >
													<input class="col-md-2" type="text" placeholder="SSN"  >
													<select class="col-md-2" id="tpMarital" name=""  title="Relationship">
															<option value="0" selected="selected">Relationship</option>
															<option value="son">Son</option>
															<option value="daughter">Daughter</option>
															<option value="stepchild">Stepchild</option>
															<option value="halfBrother">Half Brother</option>
															<option value="halfSister">Half Sister</option>
															<option value="stepBrother">Step Brother</option>
															<option value="stepSister">Step Sister</option>
															<option value="fosterChild">Foster Child</option>
															<option value="nephew">Nephew</option>
															<option value="niece">Niece</option>
															<option value="grandchild">Grand Child</option>
															<option value="grandparent">Grand Parent</option>
															<option value="parent">Parent</option>
															<option value="brother">Brother</option>
															<option value="sister">Sister</option>
															<option value="aunt">Aunt</option>
															<option value="uncle">Uncle</option>
															<option value="none">None</option>
															<option value="other">Other</option>
													</select>
													<input class="col-md-1" type="text" placeholder="Mo"  >
													<input class="col-md-1" title="(E)ligible, (S)tudent, (D)isabled, (K)idnapped, (N)one" data-toggle="tooltip" placeholder="Code"  >
												</div>
												<div class="clearfix formGroup stackedInputs">
													<input class="col-md-2" type="text" placeholder="First Name"  >
													<input class="col-md-3" type="text" placeholder="Last Name"  >
													<input class="col-md-1" type="text" placeholder="DOB"  >
													<input class="col-md-2" type="text" placeholder="SSN"  >
													<select class="col-md-2" id="tpMarital" name=""  title="Relationship">
															<option value="0" selected="selected">Relationship</option>
															<option value="son">Son</option>
															<option value="daughter">Daughter</option>
															<option value="stepchild">Stepchild</option>
															<option value="halfBrother">Half Brother</option>
															<option value="halfSister">Half Sister</option>
															<option value="stepBrother">Step Brother</option>
															<option value="stepSister">Step Sister</option>
															<option value="fosterChild">Foster Child</option>
															<option value="nephew">Nephew</option>
															<option value="niece">Niece</option>
															<option value="grandchild">Grand Child</option>
															<option value="grandparent">Grand Parent</option>
															<option value="parent">Parent</option>
															<option value="brother">Brother</option>
															<option value="sister">Sister</option>
															<option value="aunt">Aunt</option>
															<option value="uncle">Uncle</option>
															<option value="none">None</option>
															<option value="other">Other</option>
													</select>
													<input class="col-md-1" type="text" placeholder="Mo"  >
													<input class="col-md-1" title="(E)ligible, (S)tudent, (D)isabled, (K)idnapped, (N)one" data-toggle="tooltip" placeholder="Code"  >
												</div>
												<div class="clearfix formGroup stackedInputs">
													<input class="col-md-2" type="text" placeholder="First Name"  >
													<input class="col-md-3" type="text" placeholder="Last Name"  >
													<input class="col-md-1" type="text" placeholder="DOB"  >
													<input class="col-md-2" type="text" placeholder="SSN"  >
													<select class="col-md-2" id="tpMarital" name=""  title="Relationship">
															<option value="0" selected="selected">Relationship</option>
															<option value="son">Son</option>
															<option value="daughter">Daughter</option>
															<option value="stepchild">Stepchild</option>
															<option value="halfBrother">Half Brother</option>
															<option value="halfSister">Half Sister</option>
															<option value="stepBrother">Step Brother</option>
															<option value="stepSister">Step Sister</option>
															<option value="fosterChild">Foster Child</option>
															<option value="nephew">Nephew</option>
															<option value="niece">Niece</option>
															<option value="grandchild">Grand Child</option>
															<option value="grandparent">Grand Parent</option>
															<option value="parent">Parent</option>
															<option value="brother">Brother</option>
															<option value="sister">Sister</option>
															<option value="aunt">Aunt</option>
															<option value="uncle">Uncle</option>
															<option value="none">None</option>
															<option value="other">Other</option>
													</select>
													<input class="col-md-1" type="text" placeholder="Mo"  >
													<input class="col-md-1" title="(E)ligible, (S)tudent, (D)isabled, (K)idnapped, (N)one" data-toggle="tooltip" placeholder="Code"  >
												</div>
												<div class="clearfix formGroup stackedInputs">
													<input class="col-md-2" type="text" placeholder="First Name"  >
													<input class="col-md-3" type="text" placeholder="Last Name"  >
													<input class="col-md-1" type="text" placeholder="DOB"  >
													<input class="col-md-2" type="text" placeholder="SSN"  >
													<select class="col-md-2" id="tpMarital" name=""  title="Relationship">
															<option value="0" selected="selected">Relationship</option>
															<option value="son">Son</option>
															<option value="daughter">Daughter</option>
															<option value="stepchild">Stepchild</option>
															<option value="halfBrother">Half Brother</option>
															<option value="halfSister">Half Sister</option>
															<option value="stepBrother">Step Brother</option>
															<option value="stepSister">Step Sister</option>
															<option value="fosterChild">Foster Child</option>
															<option value="nephew">Nephew</option>
															<option value="niece">Niece</option>
															<option value="grandchild">Grand Child</option>
															<option value="grandparent">Grand Parent</option>
															<option value="parent">Parent</option>
															<option value="brother">Brother</option>
															<option value="sister">Sister</option>
															<option value="aunt">Aunt</option>
															<option value="uncle">Uncle</option>
															<option value="none">None</option>
															<option value="other">Other</option>
													</select>
													<input class="col-md-1" type="text" placeholder="Mo"  >
													<input class="col-md-1" title="(E)ligible, (S)tudent, (D)isabled, (K)idnapped, (N)one" data-toggle="tooltip" placeholder="Code"  >
												</div>