anchor.diff:    </div>
   
     <div class="form-group">
  -      <fieldset id="dob">
  -        <legend id="dob-label">Date of birth</legend>
  -        <label for="dob_month">Month
  -          <input id="dob_month" name="dob_month" type="month" required />
  -        </label>
  -        <label for="dob_day">Day
  -          <input id="dob_day" name="dob_day" type="day" required />
  -        </label>
  -        <label for="dob_year">Year
  -          <input id="dob_year" name="dob_year" type="year" required />
  -        </label>
  -      </fieldset>
  -  </div>
  -
  -  <div class="form-group">
  -      <label for="ssn">Social Security Number</label>
  -      <input for="ssn" name="ssn" type="text" placeholder="000-33-0000" />
  -      <span class="help-block">You may be able to receive Medi-Cal even if you do not have a Social Security Number.</span>
  +    <fieldset id="dob">
  +      <legend id="dob-label">Date of birth</legend>
  +      <label for="dob_month">Month
  +        <input id="dob_month" name="dob_month" type="month" required />
  +      </label>
  +      <label for="dob_day">Day
  +        <input id="dob_day" name="dob_day" type="day" required />
  +      </label>
  +      <label for="dob_year">Year
  +        <input id="dob_year" name="dob_year" type="year" required />
  +      </label>
  +    </fieldset>
     </div>
   
     <div class="form-group">
  
positive.code:   </div>
  
    <div class="form-group">
      <fieldset id="citizen-field">
        <legend id="citizen-label">Are you a U.S. citizen or national?</legend>
          <label for="citizen_yes" class="radio-inline">
           <input type="radio" name="citizen" id="citizen_yes" value="Yes" required />
           Yes
          </label>
          <label for="citizen_no" class="radio-inline">
            <input type="radio" name="citizen" id="citizen_no" value="No" required />
            No
          </label>
        <fieldset id="us-entry-dates">
          <legend id="us-entry-dates-label">If "No," on what date did you enter the U.S.?</legend>
          <label for="us_entry_month">
            Month
            <input id="us_entry_month" name="us_entry_month" type="month" required />
          </label>
          <label for="us_entry_day">
            Day
            <input id="us_entry_day" name="us_entry_day" type="day" required />
          </label>
          <label for="us_entry_year">
            Year
            <input id="us_entry_year" name="us_entry_year" type="year" required />
          </label>
        </fieldset>
      </fieldset>
    </div>
  
  
negative.code: <h1>Apply for Medi-Cal</h1>
  <hr>
  <form role="form" class="form-horizontal" name="apply" action="applications" method="post">
    <div class="row">
      <div class="form-group col-sm-5">
        <label for="name_first">First name</label>
          <input type="text" name="name_first" id="name_first" placeholder="Juanita" class="form-control" required />
          <span class="help-block">Your legal first name.</span>
      </div>
  
      <div class="form-group col-sm-2">
        <label for="name_middle_initial">Middle initial</label>
          <input type="text" name="name_middle_initial" id="name_middle_initial" placeholder="Q" class="form-control" />
          <span class="help-block">The initial of your legal middle name, if you have one.</span>
      </div>
  
      <div class="form-group col-sm-6">
        <label for="name_last">Last name</label>
          <input type="text" name="name_last" id="name_last" placeholder="Smith" class="form-control" required />
          <span class="help-block">Your legal last name.</span>
      </div>
    </div>
  
    <div class="row">
      <div class="form-group col-sm-9">
        <label for="home_address">Address
          <input type="text" class="form-control col-sm-9" name="home_address" placeholder="1234 Example Street" required />
        </label>
      </div>
      <div class="form-group col-sm-3">
        <label for="home_apt">Apartment number
          <input type="text" class="form-control col-sm-3" name="home_apt" placeholder="Apt. 3" /><!-- @todo: Determine whether this needs to be in a separate field on the PDF for it to be usable. -->
        </label>
      </div>
    </div>
  
    <div class="row">
      <div class="form-group col-sm-9">
        <label for="home_city">City <!-- @todo: Reconcile with home_city_state -->
          <input type="text" class="form-control col-sm-9" name="home_city" placeholder="San Francisco" required>
        </label>
        <span class="help-block">You have to live in California to be eligible for Medi-Cal. If you don't live in California, apply for Medicaid.</span>
      </div>
      <div class="form_group col-sm-3">
        <label for="zip">ZIP code
          <input type="text" class="form-control col-sm-3" name="home_zip_code" placeholder="941..." required>
        </label>
      </div>
    </div>
  
    <!-- State: CA -->
  