Total Months Received in State[field-value] 
Total Months Received Other States[field-value] 

Months Received In State

Number of MonthsStart PeriodEnd PeriodCase Reference
[field-value][Date][Date][Case Reference No.]

Months Received In Other States

Number of MonthsStart PeriodEnd PeriodState
[field-value][Date][Date][field-value]

Exemption

ReasonStart PeriodEnd PeriodCase Reference
[field-value][Date][Date][Case Reference No.]

Extension

ReasonStart PeriodEnd PeriodCase Reference
[field-value][Date][Date][Case Reference No.]