@axos-web-dev/shared-components 0.0.110 → 0.0.112

package/dist/Forms/CpraRequest.js

@@ -0,0 +1,733 @@
+"use client";
+import { jsx, jsxs } from "react/jsx-runtime";
+import { zodResolver } from "@hookform/resolvers/zod";
+import { Button } from "../Button/Button.js";
+import "../Button/Button.css.js";
+import { useState } from "react";
+import "react-use";
+import "../Input/Checkbox.js";
+import "../Input/CurrencyInput.js";
+import { Dropdown } from "../Input/Dropdown.js";
+/* empty css                                              */
+/* empty css                                       */
+import { Input } from "../Input/Input.js";
+import "../Input/Input.css.js";
+import "../Input/InputAmount.js";
+import { InputPhone } from "../Input/InputPhone.js";
+import "../Input/InputTextArea.js";
+import "../icons/ArrowIcon/ArrowIcon.css.js";
+import SvgAxosX from "../icons/AxosX/index.js";
+import SvgComponent from "../icons/AxosX/Blue.js";
+import "../icons/CheckIcon/CheckIcon.css.js";
+/* empty css                                    */
+/* empty css                                       */
+/* empty css                                                        */
+/* empty css                                                    */
+import { getVariant } from "../utils/getVariant.js";
+import clsx from "clsx";
+import { useForm, FormProvider } from "react-hook-form";
+import * as z from "zod";
+import { formContainer, iconForm, headerContainer, form, descriptionField, formWrapper, fullRowForm, disclosureForm, actions } from "./Forms.css.js";
+import { RadioButtonSet, RadioButton } from "../Input/RadioButton.js";
+import CheckboxGroup from "../Input/CheckboxGroup.js";
+const CpraRequest = ({
+  icon = false,
+  children,
+  onSubmit = (values) => {
+    console.log(values);
+  },
+  disclosure,
+  variant: fullVariant = "primary",
+  headline,
+  description,
+  callToAction,
+  id
+}) => {
+  const schema = z.object({
+    California_Resident: z.string(),
+    Categories_of_personal_info: z.string(),
+    Pieces_of_personal_information: z.string(),
+    Request_Correction_of_Information: z.string(),
+    Corrected_Information: z.string(),
+    Delete_personal_info: z.string(),
+    Opt_out_of_sale_of_info: z.string(),
+    Current_client: z.string(),
+    Currently_Employed_by_Axos_Financial: z.string(),
+    Previously_Employed_by_Axos_Financial: z.string(),
+    Ever_Applied_for_Employment_with_Axos_Financial: z.string(),
+    Axos_Financial_interaction_outlet: z.string(),
+    "Street Address": z.string(),
+    City: z.string(),
+    State: z.string(),
+    "Zip Code": z.string().regex(/^\d{5}(-\d{4})?$/, { message: "Invalid Zip Code format." }),
+    Contact_Method: z.string(),
+    DOB: z.string(),
+    First_Name: z.string().regex(/^[A-Za-z][^0-9_!¡?÷?¿/\\+=@#$%ˆ&*,.^(){}|~<>;:[\]]{1,}$/g).trim().min(1, { message: "First Name is required." }),
+    Last_Name: z.string().regex(/^[A-Za-z][^0-9_!¡?÷?¿/\\+=@#$%ˆ&*,.^(){}|~<>;:[\]]{1,}$/g).trim().min(1, { message: "Last Name is required." }),
+    email: z.string().email({ message: "Email is required." }),
+    Telephone: z.string().regex(/[\d-]{10}/).min(10, { message: "Phone is required." }).max(12, { message: "Phone is required." }).transform((val, ctx) => {
+      const removeDashes = val.replace(/-/gi, "");
+      if (removeDashes.length !== 10) {
+        ctx.addIssue({
+          code: z.ZodIssueCode.custom,
+          message: "Phone must have at least 10 and no more than 10 characters."
+        });
+        return z.NEVER;
+      }
+      return removeDashes;
+    })
+  });
+  const methods = useForm({
+    resolver: zodResolver(schema, {
+      async: true
+    }),
+    mode: "all"
+  });
+  const {
+    handleSubmit,
+    register,
+    setValue,
+    watch,
+    formState: { errors, isValid, isSubmitting }
+  } = methods;
+  const submitForm = async (data) => {
+    await onSubmit(data);
+  };
+  const variant = getVariant(fullVariant);
+  const options = [
+    { label: "Address", value: "Address" },
+    { label: "Name", value: "Name" },
+    { label: "Phone Number", value: "Phone Number" },
+    { label: "Date of Birth", value: "Date of Birth" },
+    { label: "Email", value: "Email" }
+  ];
+  const options2 = [
+    { label: "Axos Bank", value: "Axos Bank" },
+    {
+      label: "Nationwide banking services provided by Axos Bank",
+      value: "Nationwide banking services provided by Axos Bank"
+    },
+    { label: "UFB Direct", value: "UFB Direct" },
+    { label: "Other", value: "Other" }
+  ];
+  const [selectedValues, setSelectedValues] = useState([]);
+  const [selectedValues2, setSelectedValues2] = useState([]);
+  const requestCorrectionOfInfo = watch("Request_Correction_of_Information");
+  const handleSelectedValues = (updatedValues) => {
+    if (updatedValues) {
+      setSelectedValues(updatedValues);
+      setValue("Corrected_Information", updatedValues.join(";"));
+    }
+  };
+  const handleSelectedValues2 = (updatedValues) => {
+    if (updatedValues) {
+      setSelectedValues2(updatedValues);
+      setValue("Axos_Financial_interaction_outlet", updatedValues.join(";"));
+    }
+  };
+  return /* @__PURE__ */ jsx(
+    "section",
+    {
+      id: `id_${id}`,
+      className: clsx(formContainer({ variant })),
+      children: /* @__PURE__ */ jsx("div", { className: clsx("containment"), children: /* @__PURE__ */ jsxs(FormProvider, { ...methods, children: [
+        icon && /* @__PURE__ */ jsx("div", { className: clsx("text_center", iconForm), children: ["primary", "secondary"].includes(variant) ? /* @__PURE__ */ jsx(SvgComponent, {}) : /* @__PURE__ */ jsx(SvgAxosX, {}) }),
+        /* @__PURE__ */ jsxs("div", { className: `${headerContainer}`, children: [
+          /* @__PURE__ */ jsx("h2", { className: `header_2 ${form} ${descriptionField({ variant })}`, children: headline }),
+          description && /* @__PURE__ */ jsx("div", { className: `${form} ${descriptionField({ variant })}`, children: description })
+        ] }),
+        /* @__PURE__ */ jsxs("div", { className: `${headerContainer}`, children: [
+          /* @__PURE__ */ jsx("h2", { className: `header_2 ${form} ${descriptionField({ variant })}`, children: "Step 1: Please identify which privacy right(s) you would like to exercise." }),
+          /* @__PURE__ */ jsxs("div", { className: `${form} ${descriptionField({ variant })}`, children: [
+            /* @__PURE__ */ jsx("u", { children: "Right to Access:" }),
+            " You have the right to send Axos Financial a verifiable request, twice in a 12-month period, asking that we disclose to you the personal information Axos Financial has collected, used, disclosed and sold about you during the past 12 months. Please check the box below relating to the information you would like Axos Financial to disclose to you:"
+          ] })
+        ] }),
+        /* @__PURE__ */ jsxs("form", { className: form, onSubmit: handleSubmit(submitForm), children: [
+          /* @__PURE__ */ jsxs("div", { className: clsx(formWrapper({ variant })), children: [
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+              RadioButtonSet,
+              {
+                id: "California_Resident",
+                label: "* Are you a California resident?",
+                sizes: "medium",
+                required: true,
+                error: !!errors.California_Resident,
+                helperText: errors.California_Resident?.message,
+                variant,
+                children: [
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("California_Resident", {}),
+                      value: "Yes",
+                      radioText: "Yes",
+                      groupName: "California_Resident"
+                    }
+                  ),
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("California_Resident", {}),
+                      value: "No",
+                      radioText: "No",
+                      groupName: "California_Resident"
+                    }
+                  )
+                ]
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+              RadioButtonSet,
+              {
+                id: "Categories_of_personal_info",
+                label: "* The categories of personal information Axos Financial has collected about you.",
+                sizes: "medium",
+                required: true,
+                error: !!errors.Categories_of_personal_info,
+                helperText: errors.Categories_of_personal_info?.message,
+                variant,
+                children: [
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Categories_of_personal_info", {}),
+                      value: "Yes",
+                      radioText: "Yes",
+                      groupName: "Categories_of_personal_info"
+                    }
+                  ),
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Categories_of_personal_info", {}),
+                      value: "No",
+                      radioText: "No",
+                      groupName: "Categories_of_personal_info"
+                    }
+                  )
+                ]
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+              RadioButtonSet,
+              {
+                id: "Pieces_of_personal_information",
+                label: "* The specific pieces of personal information Axos Financial has collected about you.",
+                sizes: "medium",
+                required: true,
+                error: !!errors.Pieces_of_personal_information,
+                helperText: errors.Pieces_of_personal_information?.message,
+                variant,
+                children: [
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Pieces_of_personal_information", {}),
+                      value: "Yes",
+                      radioText: "Yes",
+                      groupName: "Pieces_of_personal_information"
+                    }
+                  ),
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Pieces_of_personal_information", {}),
+                      value: "No",
+                      radioText: "No",
+                      groupName: "Pieces_of_personal_information"
+                    }
+                  )
+                ]
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx("div", { className: `${form} ${descriptionField({ variant })}`, children: "By selecting specific pieces of personal information Axos Financial has collected about you, you are required to sign a declaration, under penalty of perjury, that you are the individual whose information is provided above. We will provide you with the form and instructions at your preferred contact method. If you do not return the completed form, we will not be able to provide you with the specific pieces of personal information Axos Financial has collected about you." }) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+              RadioButtonSet,
+              {
+                id: "Request_Correction_of_Information",
+                label: "Request correction of information?",
+                sizes: "medium",
+                required: true,
+                error: !!errors.Request_Correction_of_Information,
+                helperText: errors.Request_Correction_of_Information?.message,
+                variant,
+                children: [
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Request_Correction_of_Information", {}),
+                      value: "Yes",
+                      radioText: "Yes",
+                      groupName: "Request_Correction_of_Information"
+                    }
+                  ),
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Request_Correction_of_Information", {}),
+                      value: "No",
+                      radioText: "No",
+                      groupName: "Request_Correction_of_Information"
+                    }
+                  )
+                ]
+              }
+            ) }),
+            requestCorrectionOfInfo === "Yes" && /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+              CheckboxGroup,
+              {
+                options,
+                selectedValues,
+                error: !!errors.Corrected_Information,
+                onChange: handleSelectedValues
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs("div", { className: `${form} ${descriptionField({ variant })}`, children: [
+              /* @__PURE__ */ jsx("u", { children: "Right to Delete:" }),
+              " You have the right to submit a verifiable request asking that Axos Financial delete certain personal information Axos Financial has collected from you, subject to certain exceptions as permitted by law."
+            ] }) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+              RadioButtonSet,
+              {
+                id: "Delete_personal_info",
+                label: "* Would you like Axos Financial to delete the personal information we have collected from you?",
+                sizes: "medium",
+                required: true,
+                error: !!errors.Delete_personal_info,
+                helperText: errors.Delete_personal_info?.message,
+                variant,
+                children: [
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Delete_personal_info", {}),
+                      value: "Yes",
+                      radioText: "Yes",
+                      groupName: "Delete_personal_info"
+                    }
+                  ),
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Delete_personal_info", {}),
+                      value: "No",
+                      radioText: "No",
+                      groupName: "Delete_personal_info"
+                    }
+                  )
+                ]
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs("div", { className: `${form} ${descriptionField({ variant })}`, children: [
+              /* @__PURE__ */ jsx("u", { children: "Right to Opt-Out of Sale:" }),
+              " You have the right to opt-out of the sale of your personal information we collect on our websites, such as to enhance the ability to serve you content and advertisements that may be of interest to you."
+            ] }) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+              RadioButtonSet,
+              {
+                id: "Opt_out_of_sale_of_info",
+                label: "* Would you like to opt out of the sale of your personal information by Axos Financial?",
+                sizes: "medium",
+                required: true,
+                error: !!errors.Opt_out_of_sale_of_info,
+                helperText: errors.Opt_out_of_sale_of_info?.message,
+                variant,
+                children: [
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Opt_out_of_sale_of_info", {}),
+                      value: "Yes",
+                      radioText: "Yes",
+                      groupName: "Opt_out_of_sale_of_info"
+                    }
+                  ),
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Opt_out_of_sale_of_info", {}),
+                      value: "No",
+                      radioText: "No",
+                      groupName: "Opt_out_of_sale_of_info"
+                    }
+                  )
+                ]
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${headerContainer} ${fullRowForm}`, children: /* @__PURE__ */ jsx("h2", { className: `header_2 ${descriptionField({ variant })}`, children: "Step 2: Please provide the following information so that we can verify your identity and respond to your request." }) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+              RadioButtonSet,
+              {
+                id: "Current_client",
+                label: "* I am a current or former client or customer.",
+                sizes: "medium",
+                required: true,
+                error: !!errors.Current_client,
+                helperText: errors.Current_client?.message,
+                variant,
+                children: [
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Current_client", {}),
+                      value: "Yes",
+                      radioText: "Yes",
+                      groupName: "Current_client"
+                    }
+                  ),
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Current_client", {}),
+                      value: "No",
+                      radioText: "No",
+                      groupName: "Current_client"
+                    }
+                  )
+                ]
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+              RadioButtonSet,
+              {
+                id: "Currently_Employed_by_Axos_Financial",
+                label: "* Are you currently employed by Axos Financial?",
+                sizes: "medium",
+                required: true,
+                error: !!errors.Currently_Employed_by_Axos_Financial,
+                helperText: errors.Currently_Employed_by_Axos_Financial?.message,
+                variant,
+                children: [
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Currently_Employed_by_Axos_Financial", {}),
+                      value: "Yes",
+                      radioText: "Yes",
+                      groupName: "Currently_Employed_by_Axos_Financial"
+                    }
+                  ),
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Currently_Employed_by_Axos_Financial", {}),
+                      value: "No",
+                      radioText: "No",
+                      groupName: "Currently_Employed_by_Axos_Financial"
+                    }
+                  )
+                ]
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+              RadioButtonSet,
+              {
+                id: "Previously_Employed_by_Axos_Financial",
+                label: "* Have you previously been employed by Axos Financial?",
+                sizes: "medium",
+                required: true,
+                error: !!errors.Previously_Employed_by_Axos_Financial,
+                helperText: errors.Previously_Employed_by_Axos_Financial?.message,
+                variant,
+                children: [
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Previously_Employed_by_Axos_Financial", {}),
+                      value: "Yes",
+                      radioText: "Yes",
+                      groupName: "Previously_Employed_by_Axos_Financial"
+                    }
+                  ),
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Previously_Employed_by_Axos_Financial", {}),
+                      value: "No",
+                      radioText: "No",
+                      groupName: "Previously_Employed_by_Axos_Financial"
+                    }
+                  )
+                ]
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+              RadioButtonSet,
+              {
+                id: "Ever_Applied_for_Employment_with_Axos_Financial",
+                label: "* Have you ever applied for employment with Axos Financial?",
+                sizes: "medium",
+                required: true,
+                error: !!errors.Ever_Applied_for_Employment_with_Axos_Financial,
+                helperText: errors.Ever_Applied_for_Employment_with_Axos_Financial?.message,
+                variant,
+                children: [
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register(
+                        "Ever_Applied_for_Employment_with_Axos_Financial",
+                        {}
+                      ),
+                      value: "Yes",
+                      radioText: "Yes",
+                      groupName: "Ever_Applied_for_Employment_with_Axos_Financial"
+                    }
+                  ),
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register(
+                        "Ever_Applied_for_Employment_with_Axos_Financial",
+                        {}
+                      ),
+                      value: "No",
+                      radioText: "No",
+                      groupName: "Ever_Applied_for_Employment_with_Axos_Financial"
+                    }
+                  )
+                ]
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${headerContainer} ${fullRowForm}`, children: /* @__PURE__ */ jsx("h2", { className: `header_2 ${descriptionField({ variant })}`, children: "Step 3: Where have you interacted with Axos Financial?" }) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+              CheckboxGroup,
+              {
+                options: options2,
+                selectedValues: selectedValues2,
+                error: !!errors.Axos_Financial_interaction_outlet,
+                onChange: handleSelectedValues2
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${headerContainer} ${fullRowForm}`, children: /* @__PURE__ */ jsx("h2", { className: `header_2 ${descriptionField({ variant })}`, children: "Step 4: Please provide your contact details." }) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+              Input,
+              {
+                id: "First_Name",
+                ...register("First_Name", { required: true }),
+                label: "First Name",
+                sizes: "medium",
+                placeholder: "First Name",
+                required: true,
+                error: !!errors.First_Name,
+                helperText: errors.First_Name?.message,
+                variant
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+              Input,
+              {
+                id: "Last_Name",
+                ...register("Last_Name", { required: true }),
+                label: "Last Name",
+                sizes: "medium",
+                required: true,
+                error: !!errors.Last_Name,
+                helperText: errors.Last_Name?.message,
+                variant
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+              Input,
+              {
+                id: "DOB",
+                ...register("DOB", {
+                  required: true
+                }),
+                type: "date",
+                label: "Date of Birth",
+                sizes: "medium",
+                placeholder: "Date of Birth",
+                required: true,
+                error: !!errors.DOB,
+                helperText: errors.DOB?.message,
+                variant
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+              Input,
+              {
+                id: "email",
+                ...register("email", {
+                  required: true
+                  // validate: {
+                  //   isValid: associatedEmail,
+                  // },
+                }),
+                label: "Email",
+                sizes: "medium",
+                required: true,
+                error: !!errors.email,
+                helperText: errors.email?.message,
+                variant
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+              InputPhone,
+              {
+                id: "Telephone",
+                ...register("Telephone", { required: true, maxLength: 12 }),
+                label: "Preferred Phone",
+                sizes: "medium",
+                required: true,
+                error: !!errors.Telephone,
+                helperText: errors.Telephone?.message,
+                variant
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+              Input,
+              {
+                id: "Street_Address",
+                ...register("Street Address", { required: true }),
+                label: "Street Address",
+                sizes: "medium",
+                required: true,
+                variant
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+              Input,
+              {
+                id: "City",
+                ...register("City", { required: true }),
+                label: "City",
+                sizes: "medium",
+                required: true,
+                variant
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+              Dropdown,
+              {
+                id: "State",
+                ...register("State", {
+                  required: true
+                }),
+                label: "Assets Under Management",
+                sizes: "medium",
+                required: true,
+                error: !!errors.State,
+                helperText: errors.State?.message,
+                variant,
+                children: [
+                  /* @__PURE__ */ jsx("option", { value: "Alabama - AL", children: "Alabama - AL" }),
+                  /* @__PURE__ */ jsx("option", { value: "Alaska - AK", children: "Alaska - AK" }),
+                  /* @__PURE__ */ jsx("option", { value: "Arizona - AZ", children: "Arizona - AZ" }),
+                  /* @__PURE__ */ jsx("option", { value: "Arkansas - AR", children: "Arkansas - AR" }),
+                  /* @__PURE__ */ jsx("option", { value: "California - CA", children: "California - CA" }),
+                  /* @__PURE__ */ jsx("option", { value: "Colorado - CO", children: "Colorado - CO" }),
+                  /* @__PURE__ */ jsx("option", { value: "Connecticut - CT", children: "Connecticut - CT" }),
+                  /* @__PURE__ */ jsx("option", { value: "Delaware - DE", children: "Delaware - DE" }),
+                  /* @__PURE__ */ jsx("option", { value: "Florida - FL", children: "Florida - FL" }),
+                  /* @__PURE__ */ jsx("option", { value: "Georgia - GA", children: "Georgia - GA" }),
+                  /* @__PURE__ */ jsx("option", { value: "Hawaii - HI", children: "Hawaii - HI" }),
+                  /* @__PURE__ */ jsx("option", { value: "Idaho - ID", children: "Idaho - ID" }),
+                  /* @__PURE__ */ jsx("option", { value: "Illinois - IL", children: "Illinois - IL" }),
+                  /* @__PURE__ */ jsx("option", { value: "Indiana - IN", children: "Indiana - IN" }),
+                  /* @__PURE__ */ jsx("option", { value: "Iowa - IA", children: "Iowa - IA" }),
+                  /* @__PURE__ */ jsx("option", { value: "Kansas - KS", children: "Kansas - KS" }),
+                  /* @__PURE__ */ jsx("option", { value: "Kentucky - KY", children: "Kentucky - KY" }),
+                  /* @__PURE__ */ jsx("option", { value: "Louisiana - LA", children: "Louisiana - LA" }),
+                  /* @__PURE__ */ jsx("option", { value: "Maine - ME", children: "Maine - ME" }),
+                  /* @__PURE__ */ jsx("option", { value: "Maryland - MD", children: "Maryland - MD" }),
+                  /* @__PURE__ */ jsx("option", { value: "Massachusetts - MA", children: "Massachusetts - MA" }),
+                  /* @__PURE__ */ jsx("option", { value: "Michigan - MI", children: "Michigan - MI" }),
+                  /* @__PURE__ */ jsx("option", { value: "Minnesota - MN", children: "Minnesota - MN" }),
+                  /* @__PURE__ */ jsx("option", { value: "Mississippi - MS", children: "Mississippi - MS" }),
+                  /* @__PURE__ */ jsx("option", { value: "Missouri - MO", children: "Missouri - MO" }),
+                  /* @__PURE__ */ jsx("option", { value: "Montana - MT", children: "Montana - MT" }),
+                  /* @__PURE__ */ jsx("option", { value: "Nebraska - NE", children: "Nebraska - NE" }),
+                  /* @__PURE__ */ jsx("option", { value: "Nevada - NV", children: "Nevada - NV" }),
+                  /* @__PURE__ */ jsx("option", { value: "New Hampshire - NH", children: "New Hampshire - NH" }),
+                  /* @__PURE__ */ jsx("option", { value: "New Jersey - NJ", children: "New Jersey - NJ" }),
+                  /* @__PURE__ */ jsx("option", { value: "New Mexico - NM", children: "New Mexico - NM" }),
+                  /* @__PURE__ */ jsx("option", { value: "New York - NY", children: "New York - NY" }),
+                  /* @__PURE__ */ jsx("option", { value: "North Carolina - NC", children: "North Carolina - NC" }),
+                  /* @__PURE__ */ jsx("option", { value: "North Dakota - ND", children: "North Dakota - ND" }),
+                  /* @__PURE__ */ jsx("option", { value: "Ohio - OH", children: "Ohio - OH" }),
+                  /* @__PURE__ */ jsx("option", { value: "Oklahoma - OK", children: "Oklahoma - OK" }),
+                  /* @__PURE__ */ jsx("option", { value: "Oregon - OR", children: "Oregon - OR" }),
+                  /* @__PURE__ */ jsx("option", { value: "Pennsylvania - PA", children: "Pennsylvania - PA" }),
+                  /* @__PURE__ */ jsx("option", { value: "Rhode Island - RI", children: "Rhode Island - RI" }),
+                  /* @__PURE__ */ jsx("option", { value: "South Carolina - SC", children: "South Carolina - SC" }),
+                  /* @__PURE__ */ jsx("option", { value: "South Dakota - SD", children: "South Dakota - SD" }),
+                  /* @__PURE__ */ jsx("option", { value: "Tennessee - TN", children: "Tennessee - TN" }),
+                  /* @__PURE__ */ jsx("option", { value: "Texas - TX", children: "Texas - TX" }),
+                  /* @__PURE__ */ jsx("option", { value: "Utah - UT", children: "Utah - UT" }),
+                  /* @__PURE__ */ jsx("option", { value: "Vermont - VT", children: "Vermont - VT" }),
+                  /* @__PURE__ */ jsx("option", { value: "Virginia - VA", children: "Virginia - VA" }),
+                  /* @__PURE__ */ jsx("option", { value: "Washington - WA", children: "Washington - WA" }),
+                  /* @__PURE__ */ jsx("option", { value: "West Virginia - WV", children: "West Virginia - WV" }),
+                  /* @__PURE__ */ jsx("option", { value: "Wisconsin - WI", children: "Wisconsin - WI" }),
+                  /* @__PURE__ */ jsx("option", { value: "Wyoming - WY", children: "Wyoming - WY" })
+                ]
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+              Input,
+              {
+                id: "Zip_Code",
+                ...register("Zip Code", { required: true }),
+                label: "Zip Code",
+                sizes: "medium",
+                required: true,
+                variant
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${headerContainer} ${fullRowForm}`, children: /* @__PURE__ */ jsx("h2", { className: `header_2 ${descriptionField({ variant })}`, children: "Step 5: Please select how you would like to receive our response." }) }),
+            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+              RadioButtonSet,
+              {
+                id: "Contact_Method",
+                label: "* We will contact you using the information provided above:",
+                sizes: "medium",
+                required: true,
+                error: !!errors.Contact_Method,
+                helperText: errors.Contact_Method?.message,
+                variant,
+                children: [
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Contact_Method", {}),
+                      value: "Email",
+                      radioText: "Email",
+                      groupName: "Contact_Method"
+                    }
+                  ),
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Contact_Method", {}),
+                      value: "Postal Mail",
+                      radioText: "Postal Mail",
+                      groupName: "Contact_Method"
+                    }
+                  )
+                ]
+              }
+            ) })
+          ] }),
+          children,
+          /* @__PURE__ */ jsx("div", { className: disclosureForm({ variant }), children: disclosure }),
+          /* @__PURE__ */ jsx("div", { className: actions, children: /* @__PURE__ */ jsx(
+            Button,
+            {
+              color: getVariant(callToAction?.variant),
+              as: "button",
+              type: "submit",
+              disabled: !isValid || isSubmitting,
+              children: callToAction?.displayText
+            }
+          ) })
+        ] })
+      ] }) })
+    },
+    id
+  );
+};
+export {
+  CpraRequest
+};