@extends('layouts.default', ['appTopMenu' => true])

<!-- @section('title','Receipt') -->
@push('scripts')
<!--<script src="{{ asset('js/typeahead.js') }}"></script>
<script src="{{ asset('js/bootstrap3-typeahead.min.js') }}"></script

<script src="{{ asset('js/autocomplete.js') }}"></script>-->
<link rel="stylesheet" href="{{ asset('css/jquery-ui.css')}}" />
<script src="{{ asset('js/jquery-ui.js') }}"></script>
    <script src="{{ asset('js/legalservices/receipt.js') }}"></script>
   <script src="{{ asset('js/bootstrap-datetimepicker.js')}}"></script>
    <!--<script src="{{ asset('js/bootstrap-datetimepicker.fr.js') }}"></script>-->
@endpush

@section('content') 
<div class="container">
@if (session('status'))

<div class="alert alert-success alert-dismissible" >
	<button type="button" class="btn-close" data-bs-dismiss="alert"></button>
	{!! session('status') !!}
</div>
@elseif(session('failed'))
<div class="alert alert-danger alert-dismissible" >
	<button type="button" class="btn-close" ddata-bs-dismiss="alert"></button>
  <strong>{{ session('failed') }}	</strong>
</div>
@endif

<form action="{{ url('/') }}/receipt_backlog" method="POST">
  @csrf
 

  <div class="card mb-0 ">
   <div class="card-header card-bg-color ">Letter Backlog Details</div>
   <div class="card-body">
     
      <div class="row mb-1">
      <label class="col-sm-2 control-label" for="txt_b_l_rec_dt"><b>Backlog Receiving Date</b><span class="cl_red"> *</span></label>
        
        <div class="col-sm-3">
        <input type="text" name="txt_b_l_rec_dt" id="txt_b_l_rec_dt" placeholder="Receiving Date" class="form-control form-control-sm dtp @error('txt_b_l_rec_dt') border border-danger @enderror" data-date-format="MM-DD-YYYY" value="{{old('txt_b_l_rec_dt')}}">
       <span class="text-danger">
        @error('txt_b_l_rec_dt')
              {{$message}}
        @enderror
        </span>
        </div>  
</div>
</div>
    </div>


<div class="card mb-0 ">
   <div class="card-header card-bg-color ">Details of Application</div>
   <div class="card-body">
     
   <div class="row mb-1">
      <div class="col-sm-3 mb-1">
        
        <label class="control-label" for="ddl_mode"><b>Mode</b><span class="cl_red"> *</span></label>
        <select name="ddl_mode" id="ddl_mode" class="form-select form-select-sm @error('ddl_mode') is-invalid @enderror">
         <option value="">Select</option>
         @foreach($getModes as $getMode)
         <option value="{{ $getMode->id }}" @if( $getMode->id ==old('ddl_mode')) {{'selected'}}  @endif>{{ $getMode->name }}</option>
         @endforeach
       </select>
        <span class="text-danger ">
        @error('ddl_mode')
              {{$message}}
        @enderror
        </span>
        </div>

        <div class="col-sm-3 mb-1">
        <label class="control-label" for="ddl_category"><b>Categoty</b><span class="cl_red"> *</span></label>
        <select name="ddl_category" id="ddl_category" class="form-select form-select-sm @error('ddl_category') border border-danger @enderror">
         <option value="">Select</option>
         @foreach($getCategorys as $getCategory)
         <option value="{{ $getCategory->id }}" @if( $getCategory->id ==old('ddl_category')) {{'selected'}}  @endif>{{ $getCategory->category }}</option>
         @endforeach
       </select>
        <span class="text-danger">
          @error('ddl_category')
             {{$message}}
          @enderror
        </span>  
      </div>
      <div class="col-sm-3 mb-1">
      <label class="control-label" for="txt_refno"><b>Letter Reference No.</b></label>
      <input type="text" name="txt_refno" id="txt_refno" placeholder="Letter Reference No." class="form-control form-control-sm @error('txt_refno') border border-danger @enderror" value="{{old('txt_refno')}}">
        <span class="text-danger">
          @error('txt_refno')
             {{$message}}
          @enderror
        </span>  
    </div>
    <div class="col-sm-3 mb-1">
    <label class="control-label" for="txt_ldate"><b>Letter Date</b></label>
    <input type="text" name="txt_ldate" id="txt_ldate" placeholder="Letter Date" class="form-control form-control-sm dtp @error('txt_ldate') border border-danger @enderror" data-date-format="MM-DD-YYYY" value="{{old('txt_ldate')}}">
       <span class="text-danger">
        @error('txt_ldate')
              {{$message}}
        @enderror
        </span>  
  </div>
      </div>

      <div class="row mb-1">
      <div class="col-sm-3 mb-1">
    <label class="control-label" for="txt_refno"><b>Old Reference No.</b></label>
    <input type="text" name="txt_orefno" id="txt_orefno" placeholder="Old Reference No." class="form-control form-control-sm @error('txt_orefno') border border-danger @enderror" value="{{old('txt_orefno')}}">
        <span class="text-danger">
          @error('txt_orefno')
             {{$message}}
          @enderror
        </span>    
  </div>

      <div class="col-sm-6 mb-1">
      <label class="control-label" for="txt_enq_remark"><b>Subject/Remark</b></label> 
      <textarea class="form-control form-control-sm" rows="1" id="txt_enq_remark" name="txt_enq_remark">{{old('txt_enq_remark')}}</textarea>
        <span class="text-danger">
          @error('txt_enq_remark')
             {{$message}}
          @enderror
        </span> 
    </div>

      </div>
</div>
    </div>
    <div class="card mb-0">
      <div class="card-header card-bg-color ">
        Received From
        <div class="col-sm-1 offset-sm-1  form-check form-check-inline">
          
          <input type="radio" class="form-check-input cl_i_o is-valid-custom" id="rdn_individual" name="dbn_i_o" value="I" style="accent-color: green;"   @if( old('dbn_i_o') == 'I' || old('dbn_i_o')=='' ) {{ 'checked' }}  @endif>
      <label class="form-check-label" for="rdn_individual" style="color:white">Individual</label>

        <span class="help-block"></span>
        </div>
        <div class="col-sm-2 form-check form-check-inline">
          
          <input type="radio" class="form-check-input cl_i_o is-valid-custom" id="rdn_organization" name="dbn_i_o" value="O"  @if( old('dbn_i_o') == 'O' ) {{'checked' }}  @endif>
          <label class="form-check-label" for="rdn_organization" style="color:white">Organization</label>
  
          <span class="help-block"></span>
          </div>
      </div>
      <div class="card-body">
        <!-- <div class="row mb-3">
        <label class="col-sm-2 control-label" ><b>Individual/Organization</b></label>
        
        <div class="col-sm-1 form-check form-check-inline">
          
          <input type="radio" class="form-check-input cl_i_o" id="rdn_individual" name="dbn_i_o" value="I"   @if( old('dbn_i_o') == 'I' || old('dbn_i_o')=='' ) {{ 'checked' }}  @endif>
      <label class="form-check-label" for="rdn_individual">Individual</label>

        <span class="help-block"></span>
        </div>
        <div class="col-sm-2 form-check form-check-inline">
          
        <input type="radio" class="form-check-input cl_i_o" id="rdn_organization" name="dbn_i_o" value="O"  @if( old('dbn_i_o') == 'O' ) {{'checked' }}  @endif>
        <label class="form-check-label" for="rdn_organization">Organization</label>

        <span class="help-block"></span>
        </div>

        
       
         </div> -->
         <!-- <div class="card mb-3 @if(old('dbn_i_o') == 'O') d-none  @endif" id="dv_individual">
           <div class="card-header card-bg-color ">
             Individual
           </div>
            <div class="card-body"> -->

           
         <div class="row mb-0 @if(old('dbn_i_o') == 'O') d-none  @endif" id="dv_individual">
        
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="txt_name"><b>Name</b><span class="cl_red"> *</span></label>
        <input type="text" name="txt_name" id="txt_name" class="form-control form-control-sm" placeholder="Name" value="{{ old('txt_name') }}" >
        <span class="text-danger">
        @error('txt_name')
              {{$message}}
        @enderror
        </span>
        </div>
       
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="ddl_relation"><b>Relation</b></label>
        <select name="ddl_relation" id="ddl_relation" class="form-select form-select-sm">
         <option value="">Select</option>
        @foreach($getRelationDetails as $getRelationDetail)
        <option value="{{ $getRelationDetail->id }}" @if($getRelationDetail->id==old('ddl_relation')) {{ 'selected' }} @endif>{{ $getRelationDetail->name }}</option>
        @endforeach
       </select>
        <span class="help-block"></span>
        </div>
         
       
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="txt_relpnm"><b>Father/Husband Name</b></label>
        <input type="text" name="txt_relpnm" id="txt_relpnm" class="form-control form-control-sm" placeholder="Name" value="{{ old('txt_relpnm') }}">
        <span class="help-block"></span>
        </div>
       
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="txt_address"><b>Address</b><span class="cl_red"> *</span></label>
        <input type="text" name="txt_address" id="txt_address" class="form-control form-control-sm @error('txt_address') border border-danger @enderror" placeholder="Address" value="{{ old('txt_address') }}">
        <span class="text-danger">
          @error('txt_address')
             {{$message}}
          @enderror
        </span>
        </div>
        

        
        
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="ddl_state"><b>State</b><span class="cl_red"> *</span></label>
        <select name="ddl_state" id="ddl_state" class="form-select form-select-sm @error('ddl_state') border border-danger @enderror cl_ddlstate">
         <option value="">Select</option>
         @foreach($getStateDetails as $getStateDetail)
         <option value="{{$getStateDetail->state_code}}" @if(old('ddl_state')==$getStateDetail->state_code) {{'selected'}} @endif>{{$getStateDetail->state_name_english}}</option>
         @endforeach
       </select>
       <span class="text-danger">
          @error('ddl_state')
             {{$message}}
          @enderror
        </span>
        </div>
        
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="ddl_district"><b>District</b><span class="cl_red"> *</span></label>
        <select name="ddl_district" id="ddl_district" class="form-select form-select-sm @error('ddl_district') border border-danger @enderror cl_ddl_district">
         <option value="">Select</option>
         @if($getDistrictDetails && old('dbn_i_o')=='I')
         @foreach($getDistrictDetails as $getDistrictDetail)
         <option value="{{$getDistrictDetail->district_code}}" @if(old('ddl_district')==$getDistrictDetail->district_code) {{'selected'}} @endif>{{$getDistrictDetail->district_name_english}}</option>
         @endforeach
        @endif
       </select>
       <span class="text-danger">
          @error('ddl_district')
             {{$message}}
          @enderror
        </span>
        </div>
        

       
       
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="ddl_tehsil"><b>Tehsil</b></label>
        <select name="ddl_tehsil" id="ddl_tehsil" class="form-select form-select-sm cl_ddl_tehsil">
         <option value="">Select</option>
         @if($getSubDistrictDetails && old('dbn_i_o')=='I')
         @foreach($getSubDistrictDetails as $getSubDistrictDetail)
         <option value="{{$getSubDistrictDetail->subdistrict_code}}" @if(old('ddl_tehsil')==$getSubDistrictDetail->subdistrict_code) {{'selected'}} @endif>{{$getSubDistrictDetail->subdistrict_name_english}}</option>
         @endforeach
        @endif
         
       </select>
        <span class="help-block"></span>
        </div>
        
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="ddl_village"><b>Village</b></label>
        <select name="ddl_village" id="ddl_village" class="form-select form-select-sm">
         <option value="">Select</option>
         @if($getVillageDetails && old('dbn_i_o')=='I')
         @foreach($getVillageDetails as $getVillageDetail)
         <option value="{{$getVillageDetail->village_code}}" @if(old('ddl_village')==$getVillageDetail->village_code) {{'selected'}} @endif>{{$getVillageDetail->village_name_english}}</option>
         @endforeach
        @endif
        
       </select>
        <span class="help-block"></span>
        </div>
        

         
        
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="txt_pincode"><b>Pincode</b></label>
        <input type="text" name="txt_pincode" id="txt_pincode" class="form-control form-control-sm @error('txt_pincode') border border-danger  @enderror" placeholder="Pincode" value="{{old('txt_pincode')}}">
        <span class="text-danger">
          @error('txt_pincode')
          {{$message}}
          @enderror
        </span>
        </div>
        
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="txt_mobileno"><b>Mobile No.</b></label>
        <input type="text" name="txt_mobileno" id="txt_mobileno" class="form-control form-control-sm @error('txt_mobileno') border border-danger  @enderror" placeholder="Mobile No." value="{{old('txt_mobileno')}}">
        <span class="text-danger">
          @error('txt_mobileno')
          {{$message}}
          @enderror
        </span>
        </div>
        

       
        
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="txt_email"><b>Email Id</b></label>
        <input type="text" name="txt_email" id="txt_email" class="form-control form-control-sm @error('txt_email') border border-danger  @enderror" placeholder="Email Id" value="{{old('txt_email')}}">
        <span class="text-danger">
          @error('txt_email')
          {{$message}}
          @enderror
        </span>
        </div>
        </div>
        <!-- </div>
         </div> -->
<!-- 
         <div class="card mb-3 @if(old('dbn_i_o') == 'I' || old('dbn_i_o')=='') d-none  @endif" id="dv_organization">
           <div class="card-header card-bg-color ">Organization</div>
            <div class="card-body"> -->
            <div class="row @if(old('dbn_i_o') == 'I' || old('dbn_i_o')=='') d-none  @endif" id="dv_organization">
        
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="txt_oname"><b>Organization Name</b><span class="cl_red"> *</span></label>
        <input type="text" name="txt_oname" id="txt_oname" class="form-control form-control-sm @error('txt_oname') border border-danger @enderror" placeholder="Name" value="{{old('txt_oname')}}">
        <input type="hidden" name="hd_idd" id="hd_idd" value="{{old('hd_idd')}}">
        <span class="text-danger">
          @error('txt_oname')
             {{$message}}
          @enderror
        </span>
        </div>

        <div class="col-sm-3 mb-1">
        <label class="control-label" for="txt_post"><b>Post</b></label>
        <input type="text" name="txt_post" id="txt_post" class="form-control form-control-sm @error('txt_post') border border-danger @enderror" placeholder="Name" value="{{old('txt_post')}}">
        <input type="hidden" name="hd_idd_post" id="hd_idd_post" value="{{old('hd_idd_post')}}">
        <span class="text-danger">
          @error('txt_post')
             {{$message}}
          @enderror
        </span>
        </div>

        <div class="col-sm-3 mb-1">
        <label class="control-label" for="txt_name_op"><b>Name</b><span class="cl_red"> *</span></label>
        <input type="text" name="txt_name_op" id="txt_name_op" class="form-control form-control-sm" placeholder="Name" value="{{old('txt_name_op')}}" >
        <span class="text-danger">
        @error('txt_name_op')
              {{$message}}
        @enderror
        </span>
        </div>
       
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="txt_oaddress"><b>Address</b><span class="cl_red"> *</span></label>
        <input type="text" name="txt_oaddress" id="txt_oaddress" class="form-control form-control-sm @error('txt_oaddress') border border-danger @enderror" placeholder="Address" value="{{old('txt_oaddress')}}">
        <span class="text-danger">
          @error('txt_oaddress')
             {{$message}}
          @enderror
        </span>
        </div>
         

       
        
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="txt_opincode"><b>Pincode</b></label>
        <input type="text" name="txt_opincode" id="txt_opincode" class="form-control form-control-sm @error('txt_opincode') border border-danger  @enderror" placeholder="Pincode" value="{{old('txt_opincode')}}">
        <span class="text-danger">
          @error('txt_opincode')
          {{$message}}
          @enderror
        </span>
        </div>
        
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="ddl_ostate"><b>State</b><span class="cl_red"> *</span></label>
        <select name="ddl_ostate" id="ddl_ostate" class="form-select form-select-sm @error('ddl_ostate') border border-danger @enderror cl_ddlstate">
         <option value="">Select</option>
         @foreach($getStateDetails as $getStateDetail)
         <option value="{{$getStateDetail->state_code}}" @if(old('ddl_ostate')==$getStateDetail->state_code) {{'selected'}} @endif>{{$getStateDetail->state_name_english}}</option>
         @endforeach
        
       </select>
       <span class="text-danger">
          @error('ddl_ostate')
             {{$message}}
          @enderror
        </span>
        </div>
        

         
       
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="ddl_odistrict"><b>District</b><span class="cl_red"> *</span></label>
        <select name="ddl_odistrict" id="ddl_odistrict" class="form-select form-select-sm @error('ddl_odistrict') border border-danger @enderror cl_ddl_district">
         <option value="">Select</option>
         @if($getDistrictDetails && old('dbn_i_o')=='O')
         @foreach($getDistrictDetails as $getDistrictDetail)
         <option value="{{$getDistrictDetail->district_code}}" @if(old('ddl_odistrict')==$getDistrictDetail->district_code) {{'selected'}} @endif>{{$getDistrictDetail->district_name_english}}</option>
         @endforeach
        @endif
        
       </select>
       <span class="text-danger">
          @error('ddl_odistrict')
             {{$message}}
          @enderror
        </span>
        </div>
       
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="txt_otehsil"><b>Tehsil</b></label>
        <select name="txt_otehsil" id="txt_otehsil" class="form-select form-select-sm cl_ddl_tehsil">
         <option value="">Select</option>
         @if($getSubDistrictDetails && old('dbn_i_o')=='O')
         @foreach($getSubDistrictDetails as $getSubDistrictDetail)
         <option value="{{$getSubDistrictDetail->subdistrict_code}}" @if(old('txt_otehsil')==$getSubDistrictDetail->subdistrict_code) {{'selected'}} @endif>{{$getSubDistrictDetail->subdistrict_name_english}}</option>
         @endforeach
        @endif
         
       </select>
        <span class="help-block"></span>
        </div>
         

        
        
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="ddl_ovillage"><b>Village</b></label>
        <select name="ddl_ovillage" id="ddl_ovillage" class="form-select form-select-sm">
         <option value="">Select</option>
         @if($getVillageDetails && old('dbn_i_o')=='O')
         @foreach($getVillageDetails as $getVillageDetail)
         <option value="{{$getVillageDetail->village_code}}" @if(old('ddl_ovillage')==$getVillageDetail->village_code) {{'selected'}} @endif>{{$getVillageDetail->village_name_english}}</option>
         @endforeach
        @endif
        
       </select>
        <span class="help-block"></span>
        </div>
        
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="txt_omobileno"><b>Mobile No.</b></label>
        <input type="text" name="txt_omobileno" id="txt_omobileno" class="form-control form-control-sm @error('txt_omobileno') border border-danger  @enderror" placeholder="Mobile No." value="{{old('txt_omobileno')}}">
        <span class="text-danger">
          @error('txt_omobileno')
          {{$message}}
          @enderror
        </span>
        </div>
         

         
        
        <div class="col-sm-3 mb-1">
        <label class="control-label" for="txt_oemailid"><b>Email Id</b></label>
        <input type="text" name="txt_oemailid" id="txt_oemailid" class="form-control form-control-sm @error('txt_oemailid') border border-danger  @enderror" placeholder="Email Id" value="{{old('txt_oemailid')}}">
        <span class="text-danger">
          @error('txt_oemailid')
          {{$message}}
          @enderror
        </span>
        </div>

        

        </div>

        
            <!-- </div>
         </div> -->

         
      </div>
    </div>

    <div class="card mb-0" id="dv_eligibility">
   <div class="card-header card-bg-color ">Eligibility</div>
   <div class="card-body">
     
      <div class="row">
       
        @foreach($getEligibilityMaster as $val)
                @if(session('getLegalEligibility'))