Form GEN 853, Declaration Instructions
This form contains 50 fields organized into 13 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Applicant Information | ||
| Contact/Cell Phone Number | Text |
Please enter the applicant's contact or cell phone number.
|
| Home Telephone Number | Text |
Please enter the applicant's home telephone number.
|
| Zip Code | Text |
Please enter the zip code of the applicant's address.
|
| State | Text |
Please enter the state of the applicant's address.
|
| City | Text |
Please enter the city of the applicant's address.
|
| Street Address | Text |
Please enter the street address of the applicant.
|
| Applicant Name | Text |
Please enter the full name of the applicant, including last name, first name, and middle name.
|
| Case Information | ||
| Date | Date |
Enter the current date.
|
| Case Name | Text |
Enter the name of the case.
|
| Case Number | Text |
Enter the case identification number.
|
| Worker Name | Text |
Enter the full name of the worker assigned to the case.
|
| Worker ID | Text |
Enter the identification number for the worker.
|
| Worker Phone Number | Text |
Enter the phone number of the worker.
|
| Customer ID | Text |
Enter the customer's identification number.
|
| County Information | ||
| County Information Line 1 | Text |
Provide the first line of county-related information.
|
| County Name | Text |
Enter the full name of the county.
|
| County Information Line 2 | Text |
Provide the second line of county-related information.
|
| Declaration | ||
| Declaration Statement | Text |
Please enter your declaration statement.
|
| First Signature Date | ||
| First Signature Date | Date |
Please provide the date when the first signature was signed.
|
| Footer Fields | ||
| PAGE_LABEL | Text | |
| Form Serial Number | Text |
Enter the unique serial number associated with this specific form instance.
|
| Current Page Number | Number |
Enter the current page number of the document.
|
| Total Page Count | Number |
Enter the total number of pages in the document.
|
| Footer Control Number | Text |
Enter any general control number or identifier found in the document footer.
|
| General | ||
| form1[0].PageSet[0].MasterPage1[0].Footer_1[0].#subform[0].FSPRINT[0 | Button | |
| form1[0].PageSet[0].MasterPage1[0].Footer_1[0].#subform[0].FSSUBMIT_PL[0 | Button | |
| form1[0].PageSet[0].MasterPage1[0].Footer_1[0].#subform[0].FSSUBMIT_PC[0 | Button | |
| form1[0].PageSet[0].MasterPage1[0].Footer_1[0].BTN_VISBL_CODE[0 | Text | |
| form1[0].PageSet[0].MasterPage1[0].Footer_1[0].WATERMARK_FLAG[0 | Text | |
| form1[0].PageSet[0].MasterPage1[0].Footer_1[0].NOT_SIMULATION_FLAG[0 | Text | |
| form1[0].PageSet[0].MasterPage1[0].Footer_1[0].FORM_IMG_START_NUM[0 | Text | |
| Header Fields | ||
| form1[0].Page1[0].Header_1_EN[0].COUNTY_NAME_UPPER_CASE[0 | Text | |
| form1[0].Page1[0].Header_1_EN[0].BLANK[0 | Text | |
| Header Code 1 | Text |
Enter the first identifying code or number for this header section.
|
| Header Code 2 | Text |
Enter the second identifying code or number for this header section.
|
| Middle Left Field Group | ||
| Line 1 | Text |
Please provide the text for this line.
|
| Line 2 | Text |
Please provide the text for this line.
|
| Line 3 | Text |
Please provide the text for this line.
|
| Line 4 | Text |
Please provide the text for this line.
|
| Middle Right Field Group | ||
| Line 1 | Text |
Enter any additional information or data for the first line.
|
| Line 2 | Text |
Enter any additional information or data for the second line.
|
| Line 3 | Text |
Enter any additional information or data for the third line.
|
| Line 4 | Text |
Enter any additional information or data for the fourth line.
|
| Second Signature Date | ||
| Second Date Signed | Date |
Please provide the date when the second signature was made.
|
| Top Left Field Group | ||
| Name or Organization | Text |
Please enter the name of the individual or organization associated with this document.
|
| Street Address Line 1 | Text |
Please enter the primary street address.
|
| Street Address Line 2 | Text |
Please enter any additional street address details, such as apartment, suite, or unit number.
|
| City, State, Zip Code | Text |
Please enter the city, state, and zip code.
|
| Phone Number or Email | Text |
Please enter a contact phone number or email address.
|
| Top Middle Text Field | ||
| County | Text |
Please enter the name of the county.
|