anchor.diff:    </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>
  +  </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>
  +      <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>
  +    <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>
     </div>
   
  
positive.code: <h1>Apply for Medi-Cal</h1>
  <hr>
  <form role="form" name="apply" action="applications" method="post">
    <div class="row">
      <div class="form-group col-xs-4">
        <label for="name_first">First name</label>
          <input type="text" class="form-control" name="name_first" id="name_first" placeholder="Juanita" required>
          <span class="help-block">Include your legal first name.</span>
      </div>
  
      <div class="form-group col-xs-2">
        <label for="name_middle_initial">Middle initial</label>
          <input type="text" class="form-control" name="name_middle_initial" id="name_middle_initial" placeholder="Q">
          <span class="help-block">Include the initial of your legal middle name, if you have one.</span>
      </div>
  
      <div class="form-group col-xs-5">
        <label for="name_last">Last name</label>
          <input type="text" class="form-control" name="name_last" id="name_last" placeholder="Smith" required>
          <span class="help-block">Include your legal last name.</span>
      </div>
    </div>
  
    <div class="form-group">
      <label for="name_last">Last name</label>
        <input type="text" class="form-control" name="name_last" id="name_last" placeholder="Smith" required>
        <span class="help-block">Include your legal last name.</span>
    </div>
  
    <div class="form-group">
      <label for="home_address">Address</label>
        <input type="text" class="form-control" name="home_address" placeholder="1234 Example Street" required>
      <label for="home_apt">Apartment number</label>
        <input type="text" class="form-control" 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 for="home_city">City</label> <!-- @todo: Reconcile with home_city_state -->
        <input type="text" class="form-control" name="home_city" placeholder="San Francisco" required>
        <div class="input-group">
          <input type="text" class="form-control" name="home_zip_code" placeholder="941..." required>
        </div>
        <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>
  
    <!-- State: CA -->
  
negative.code:   </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">
  