<script src="https://cdn.jotfor.ms/static/prototype.forms.js" type="text/javascript"></script> <script src="https://cdn.jotfor.ms/static/jotform.forms.js?3.3.15680" type="text/javascript"></script> <script src="https://cdn.jotfor.ms/js/vendor/math-processor.js?v=3.3.15680" type="text/javascript"></script> <script type="text/javascript"> JotForm.setCalculations([{"decimalPlaces":"2","equation":"[{6}]","ignoreHiddenFields":"","insertAsText":"","newCalculationType":"1","operands":"6","readOnly":"","replaceText":"","resultField":"8","showBeforeInput":"","showEmptyDecimals":"","useCommasForDecimals":""}]); JotForm.init(function(){ productID = {"0":"input_5_1000"}; paymentType = "subscription"; JotForm.setCurrencyFormat('USD',true, 'point'); JotForm.totalCounter({"input_5_1000":{"price":"custom"}}); JotForm.alterTexts(undefined, true); JotForm.clearFieldOnHide="disable"; JotForm.onSubmissionError="jumpToFirstError"; }); </script> <link href="https://cdn.jotfor.ms/static/formCss.css?3.3.15680" rel="stylesheet" type="text/css" /> <link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/css/styles/nova.css?3.3.15680" /> <link type="text/css" media="print" rel="stylesheet" href="https://cdn.jotfor.ms/css/printForm.css?3.3.15680" /> <link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/themes/CSS/566a91c2977cdfcd478b4567.css?"/> <style type="text/css"> .form-label-left{ width:150px !important; } .form-line{ padding-top:12px; padding-bottom:12px; } .form-label-right{ width:150px !important; } .form-all{ width:690px; color:#555 !important; font-family:"Lucida Grande", "Lucida Sans Unicode", "Lucida Sans", Verdana, sans-serif; font-size:14px; } .form-radio-item label, .form-checkbox-item label, .form-grading-label, .form-header{ color: #555; } </style> <form class="jotform-form" action="https://submit.jotform.us/submit/63160139574153/" method="post" name="form_63160139574153" id="63160139574153" accept-charset="utf-8"> <input type="hidden" name="formID" value="63160139574153" /> <div class="form-all"> <ul class="form-section page-section"> <li id="cid_11" class="form-input-wide" data-type="control_head"> <div class="form-header-group"> <div class="header-text httal htvam"> <h3 id="header_11" class="form-header"> Set Up A Reoccurring Monthly Payment </h3> <div id="subHeader_11" class="form-subHeader"> Reoccurring Payments may be canceled at http://www.dwolla.com/ </div> </div> </div> </li> <li class="form-line jf-required" data-type="control_fullname" id="id_4"> <label class="form-label form-label-left form-label-auto" id="label_4" for="input_4"> Name <span class="form-required"> * </span> </label> <div id="cid_4" class="form-input jf-required"> <span class="form-sub-label-container" style="vertical-align: top;"> <input class="form-textbox validate[required]" type="text" size="10" name="q4_name[first]" id="first_4" /> <label class="form-sub-label" for="first_4" id="sublabel_first" style="min-height: 13px;"> First Name </label> </span> <span class="form-sub-label-container" style="vertical-align: top;"> <input class="form-textbox validate[required]" type="text" size="15" name="q4_name[last]" id="last_4" /> <label class="form-sub-label" for="last_4" id="sublabel_last" style="min-height: 13px;"> Last Name </label> </span> </div> </li> <li class="form-line jf-required" data-type="control_radio" id="id_6"> <label class="form-label form-label-left form-label-auto" id="label_6" for="input_6"> Amount to Pay <span class="form-required"> * </span> </label> <div id="cid_6" class="form-input jf-required"> <div class="form-single-column"> <span class="form-radio-item" style="clear:left;"> <span class="dragger-item"> </span> <input type="radio" class="form-radio validate[required]" id="input_6_0" name="q6_amountTo" data-calcvalue="880" value="Full unit rent - $880.00" /> <label id="label_input_6_0" for="input_6_0"> Full unit rent - $880.00 </label> </span> <span class="form-radio-item" style="clear:left;"> <span class="dragger-item"> </span> <input type="radio" class="form-radio validate[required]" id="input_6_1" name="q6_amountTo" data-calcvalue="440" value="Single room rent - $440.00" /> <label id="label_input_6_1" for="input_6_1"> Single room rent - $440.00 </label> </span> <span class="form-radio-item" style="clear:left;"> <span class="dragger-item"> </span> <input type="radio" class="form-radio validate[required]" id="input_6_2" name="q6_amountTo" data-calcvalue="293.34" value="3 person unit rent - $293.34" /> <label id="label_input_6_2" for="input_6_2"> 3 person unit rent - $293.34 </label> </span> <span class="form-radio-item" style="clear:left"> <input type="radio" class="form-radio-other form-radio validate[required]" name="q6_amountTo" id="other_6" value="other" /> <input type="text" class="form-radio-other-input form-textbox" name="q6_amountTo[other]" data-otherHint="Other" size="15" id="input_6" /> <br /> </span> </div> </div> </li> <li class="form-line always-hidden" data-type="control_calculation" id="id_8"> <label class="form-label form-label-left form-label-auto" id="label_8" for="input_8"> Calculation </label> <div id="cid_8" class="form-input always-hidden jf-required"> <input type="text" data-defaultvalue="0" class="form-textbox" data-type="input-textbox" id="input_8" name="q8_calculation" value="0" size="20" /> </div> </li> <li class="form-line jf-required" data-type="control_dwolla" id="id_5"> <label class="form-label form-label-left form-label-auto" id="label_5" for="input_5"> Reoccurring Payment <span class="form-required"> * </span> </label> <div id="cid_5" class="form-input jf-required"> <input type="hidden" name="simple_fpc" data-payment_type="dwolla" value="5" /> <input type="hidden" name="payment_total_checksum" id="payment_total_checksum" /> <input type="hidden" id="payment_enable_lightbox" /> <span class="form-product-item hover-product-item"> <input class="form-radio validate[required]" type="radio" id="input_5_1000" name="q5_myProducts[][id]" value="1000" checked="checked" /> <label for="input_5_1000" class="form-product-container"> <span class="form-product-name" id="product-name-input_5_1000"> Amount </span> <span class="form-product-details"> ( <b> <input value="0" id="input_5_1000_custom_price" class="form-product-custom_price" type="text" name="q5_myProducts[custom_price_1000]" readonly data-price-source="8" /> USD </b> for each <u> month</u>.)</span> </label> </span> <br /> <br> <span class="form-payment-total"> <b> <span id="total-text"> Total: </span> &nbsp; <span class="form-payment-price">$<span id="payment_total"> 0.00 </span> </span> </b> </span> </div> </li> <li class="form-line" data-type="control_button" id="id_2"> <div id="cid_2" class="form-input-wide"> <div style="margin-left:156px" class="form-buttons-wrapper"> <button id="input_2" type="submit" class="form-submit-button"> Create Reoccurring Payment </button> </div> </div> </li> <li style="display:none"> Should be Empty: <input type="text" name="website" value="" /> </li> </ul> </div> <script> JotForm.showJotFormPowered = true; </script> <input type="hidden" id="simple_spc" name="simple_spc" value="63160139574153" /> <script type="text/javascript"> document.getElementById("si" + "mple" + "_spc").value = "63160139574153-63160139574153"; </script> </form> <script type="text/javascript">JotForm.ownerView=true;</script>