<%@ page contentType="text/html;charset=UTF-8" %>
<%@ taglib uri="http://struts.apache.org/tags-html" prefix="html-el" %>
<%@ taglib uri="/tags/struts-bean-el" prefix="bean-el" %>
<%@ taglib uri="/tags/displaytag" prefix="display" %>
<%@ taglib uri="/tags/esr-core" prefix="esrcore" %>
<%@ taglib uri="/tags/valuelist" prefix="vlh" %>
<%@ taglib uri="/tags/fw" prefix="fw" %>
<%@ taglib uri="http://java.sun.com/jsp/jstl/core" prefix="c" %>
<%@ taglib uri="/tags/authz" prefix="auth" %>
<%@ page import="gov.va.med.esr.common.model.lookup.Capability" %>


<table width="100%" border="0" cellpadding="0" cellspacing="0" class="moduleShell">
<html-el:form action="/commslog" method="post">
  <%@ include file="/admin/csrfgentoken.jsp" %>
  <tr>
    <td>
      <table width="100%" border="0" cellpadding="0" cellspacing="0" class="moduleShellTable">
        <c:set var="updateAddress" value="false"/>
       <auth:authorize ifAnyGranted="<%=Capability.UPDATE_ADDRESS%>">
          <c:set var="updateAddress" value="true"/>
        </auth:authorize>
        <c:set var="canResubmit" value="false"/>
		<auth:authorize ifAnyGranted="<%=Capability.MANAGE_ACA_COMMUNICATIONS.getName()%>">
		  <c:set var="canResubmit" value="true"/>
		</auth:authorize>
        <tr>
          <td>
            <table width="100%" border="0" cellpadding="0" cellspacing="0" class="moduleShellTableHead">
              <tr>
                <td class="moduleBlueBox"><img alt=""  src="../images/spacer.gif" width="25" height="17"/></td>
                <td nowrap style="padding-left: 7">Submit Corrected IRS 1095B Coverage Data</td>
                <td width="100%"><img alt=""  src="../images/spacer.gif"></td>

              </tr>
             </table>
          </td>
        </tr>
        <tr>
			<td colspan="2">
				<table align="center" width="100%" border="0" cellspacing="0" cellpadding="0"
					class="moduleShellTableBody" role="presentation">
					<tr>
						<td class="moduleLabel" style="vertical-align: middle;"><fw:label property="taxYears" forId="tySelect" >
								<bean-el:message key="label.comms.taxYears" />:</fw:label></td>
						<td class="moduleValue" style="vertical-align: middle;">
						<c:set var="taxYearsText">
								<bean-el:message key="label.comms.taxYears" />
							</c:set>
			               <html-el:select title="${taxYearsText}" styleId="tySelect" styleClass="moduleEdit" property="taxYearSel" >
								<esrcore:options property="taxYearList"/>
			               </html-el:select>
			               <!--
						<img alt=""  src="../images/spacer.gif">
						<img alt=""  style="vertical-align: middle;" src="../images/buttonEndLeft.gif"/><html-el:submit property="methodName" style="width:70; vertical-align: center;" styleClass="buttonText"><bean-el:message key="button.viewDataTaxYear"/></html-el:submit><img alt=""  style="vertical-align: middle;" src="../images/buttonEndRight.gif"/>
						-->
						</td>


					</tr>
					<tr>
					 <td colspan="2" style="padding: 10px 0 7px 0">
					    <table width="100%" border="0" cellpadding="0" cellspacing="0" class="moduleShellTableHead" role="presentation">
					      <tr>
					        <td class="moduleBlueBox"><img alt=""  src="../images/spacer.gif" width="25" height="17"/></td>
					        <td nowrap style="padding-left: 7px"><bean-el:message key="label.addresses.irsAddressHeader"/></td>
					        <td width="100%"><img alt=""  src="../images/spacer.gif"></td>
					         <c:choose>
				                <c:when test="${updateAddress == true}">
				                <td nowrap class="moduleBlueLink"
									style="padding: 1px 8px 1px 8px">
									<fw:link action="/demographicAddresses.do?methodName=Addresses" module="/demographic"><bean-el:message key="text.updateMailingAddressLink"/>
								</fw:link></td>
				                </c:when>
				                <c:otherwise>
				                  <bean-el:message key="text.updateMailingAddressLink"/>
				                </c:otherwise>
				                </c:choose>
				                </td>
					      </tr>
					    </table>
					  </td>
					</tr>
					<tr>
					  <td colspan="2" style="padding-top: 10px">

							<table width="100%" border="0" cellpadding="0" cellspacing="0" class="moduleShellTableBody" role="presentation">

							  <tr>
							    <td class="moduleLabel"><fw:label property="country" forId="countrySelection"><bean-el:message key="label.addresses.country" />:</fw:label></td>
							    <td class="moduleValue">
							        <esrcore:displayValue name="commsLogForm" property="address.country" nullText=""/>
							    </td>
							  </tr>


								<tr>
									<td width="45%" class="moduleLabel" id="addressLine1Label"><fw:label forId="addressLine1Id"  property="addressLine1"><bean-el:message key="label.addresses.addressLine1" />:</fw:label></td>
									<td width="55%" class="moduleValue">
										 <esrcore:displayValue name="commsLogForm" property="address.line1" nullText=""/>
									</td>
								</tr>
							<tr>
								<td class="moduleLabel"><fw:label property="addressLine2" forId="addressLine2Id"><bean-el:message key="label.addresses.addressLine2" />:</fw:label></td>
								<td width="55%" class="moduleValue">
										<esrcore:displayValue name="commsLogForm" property="address.line2" nullText=""/>
								</td>
							</tr>
							<tr>
								<td class="moduleLabel"><fw:label property="addressLine3" forId="addressLine3Id"><bean-el:message key="label.addresses.addressLine3" />:</fw:label></td>
								<td width="55%" class="moduleValue">
										<esrcore:displayValue name="commsLogForm" property="address.line3" nullText=""/>
								</td>
							</tr>
							<tr>
								<td id="zipCodeLabel" class="moduleLabel"><fw:label property="zipCode,zipPlus4" forId="zipCodeId"><bean-el:message key="label.addresses.zipCode" />:</fw:label></td>
								<td id="zipCodeEdit" class="moduleValue">
									<esrcore:displayValue name="commsLogForm" property="address.zipCode" nullText=""/> - <esrcore:displayValue name="commsLogForm" property="address.zipPlus4" nullText=""/>
								</td>
							</tr>
							<tr>
								<td class="moduleLabel" id="cityLabel"><fw:label property="city" forId="idCity" ><bean-el:message key="label.addresses.city" />:</fw:label></td>
								<td class="moduleValue">
										<esrcore:displayValue name="commsLogForm" property="address.city" nullText=""/>
								</td>
							</tr>
							<tr>
								<td id="stateLabel" class="moduleLabel"><fw:label property="state" forId="idState"><bean-el:message key="label.addresses.state" />:</fw:label></td>
								<td class="moduleValue">
										<esrcore:displayValue name="commsLogForm" property="address.state" nullText=""/>
								</td>
							</tr>
							<tr>
								<td id="countyLabel" class="moduleLabel"><fw:label property="county" forId="idCounty"><bean-el:message key="label.addresses.county" />:</fw:label></td>
								<td width="55%" class="moduleValue">
										<esrcore:displayValue name="commsLogForm" property="address.county" nullText=""/>
								</td>
							</tr>
							<tr>
								<td id="provinceLabel" class="moduleLabel"><fw:label property="province" forId="idProvince"><bean-el:message key="label.addresses.province" />:</fw:label></td>
								<td width="55%" class="moduleValue">
										<esrcore:displayValue name="commsLogForm" property="address.province" nullText=""/>
								</td>
							</tr>
							<tr>
								<td id="postalCodeLabel" class="moduleLabel"><fw:label property="postalCode" forId="idPostalCode"><bean-el:message key="label.addresses.postalCode" />:</fw:label></td>
								<td width="55%" class="moduleValue">
										<esrcore:displayValue name="commsLogForm" property="address.postalCode" nullText=""/>
								</td>
							</tr>
							</table>

					      </td>
					</tr>
					<tr>
					   <td colspan="2" style="padding: 10px 0 7px 0">
					    <table width="100%" border="0" cellpadding="0" cellspacing="0" class="moduleShellTableHead" role="presentation">
					      <tr>
					        <td class="moduleBlueBox"><img alt=""  src="../images/spacer.gif" width="25" height="17"/></td>
					        <td nowrap style="padding-left: 7px"><bean-el:message key="label.addresses.irsCoverageHeader"/></td>
					        <td width="100%"><img alt=""  src="../images/spacer.gif"></td>
					      </tr>
					    </table>
					  </td>
					</tr>
					<tr>
					  <td width="45%" class="moduleLabel" style="padding-top: 15px"><bean-el:message key="label.comms.coveredJan"/>:</td>
					  <td width="55%" class="moduleValue" style="padding-top: 15px">
					  	<c:set var="janYesText"><bean-el:message key="label.comms.coveredJan"/>&nbsp;(<bean-el:message key="label.yes"/>)</c:set>
					  	<c:set var="janNoText"><bean-el:message key="label.comms.coveredJan"/>&nbsp;(<bean-el:message key="label.no"/>)</c:set>
					    <html-el:radio title="${janYesText}" property="coveredJan" value="true" styleId="txtCoveredJan_y" /><fw:label property="coveredJan" forId="txtCoveredJan_y"><bean-el:message key="label.yes"/></fw:label>
					    <html-el:radio title="${janNoText}" property="coveredJan" value="false" styleId="txtCoveredJan_n" /><fw:label property="coveredJan" forId="txtCoveredJan_n"><bean-el:message key="label.no"/></fw:label>
					  </td>
					</tr>
					<tr>
					  <td width="45%" class="moduleLabel" style="padding-top: 15px"><bean-el:message key="label.comms.coveredFeb"/>:</td>
					  <td width="55%" class="moduleValue" style="padding-top: 15px">
					  	<c:set var="febYesText"><bean-el:message key="label.comms.coveredFeb"/>&nbsp;(<bean-el:message key="label.yes"/>)</c:set>
					  	<c:set var="febNoText"><bean-el:message key="label.comms.coveredFeb"/>&nbsp;(<bean-el:message key="label.no"/>)</c:set>
					    <html-el:radio title="${febYesText}" property="coveredFeb" value="true" styleId="txtCoveredFeb_y" /><fw:label property="coveredFeb" forId="txtCoveredFeb_y"><bean-el:message key="label.yes"/></fw:label>
					    <html-el:radio title="${febNoText}" property="coveredFeb" value="false" styleId="txtCoveredFeb_n" /><fw:label property="coveredFeb" forId="txtCoveredFeb_n"><bean-el:message key="label.no"/></fw:label>
					  </td>
					</tr>
					<tr>
					  <td width="45%" class="moduleLabel" style="padding-top: 15px"><bean-el:message key="label.comms.coveredMar"/>:</td>
					  <td width="55%" class="moduleValue" style="padding-top: 15px">
					  	<c:set var="marYesText"><bean-el:message key="label.comms.coveredMar"/>&nbsp;(<bean-el:message key="label.yes"/>)</c:set>
					  	<c:set var="marNoText"><bean-el:message key="label.comms.coveredMar"/>&nbsp;(<bean-el:message key="label.no"/>)</c:set>
					    <html-el:radio title="${marYesText}" property="coveredMar" value="true" styleId="txtCoveredMar_y" /><fw:label property="coveredMar" forId="txtCoveredMar_y"><bean-el:message key="label.yes"/></fw:label>
					    <html-el:radio title="${marNoText}" property="coveredMar" value="false" styleId="txtCoveredMar_n" /><fw:label property="coveredMar" forId="txtCoveredMar_n"><bean-el:message key="label.no"/></fw:label>
					  </td>
					</tr>
					<tr>
					  <td width="45%" class="moduleLabel" style="padding-top: 15px"><bean-el:message key="label.comms.coveredApr"/>:</td>
					  <td width="55%" class="moduleValue" style="padding-top: 15px">
					  	<c:set var="aprYesText"><bean-el:message key="label.comms.coveredApr"/>&nbsp;(<bean-el:message key="label.yes"/>)</c:set>
					  	<c:set var="aprNoText"><bean-el:message key="label.comms.coveredApr"/>&nbsp;(<bean-el:message key="label.no"/>)</c:set>
					    <html-el:radio title="${aprYesText}" property="coveredApr" value="true" styleId="txtcoveredApr_y" /><fw:label property="coveredApr" forId="txtcoveredApr_y"><bean-el:message key="label.yes"/></fw:label>
					    <html-el:radio title="${aprNoText}" property="coveredApr" value="false" styleId="txtcoveredApr_n" /><fw:label property="coveredApr" forId="txtcoveredApr_n"><bean-el:message key="label.no"/></fw:label>
					  </td>
					</tr>
					<tr>
					  <td width="45%" class="moduleLabel" style="padding-top: 15px"><bean-el:message key="label.comms.coveredMay"/>:</td>
					  <td width="55%" class="moduleValue" style="padding-top: 15px">
					  	<c:set var="mayYesText"><bean-el:message key="label.comms.coveredMay"/>&nbsp;(<bean-el:message key="label.yes"/>)</c:set>
					  	<c:set var="mayNoText"><bean-el:message key="label.comms.coveredMay"/>&nbsp;(<bean-el:message key="label.no"/>)</c:set>
					    <html-el:radio title="${mayYesText}" property="coveredMay" value="true" styleId="txtcoveredMay_y" /><fw:label property="coveredMay" forId="txtcoveredMay_y"><bean-el:message key="label.yes"/></fw:label>
					    <html-el:radio title="${mayNoText}" property="coveredMay" value="false" styleId="txtcoveredMay_n" /><fw:label property="coveredMay" forId="txtcoveredMay_n"><bean-el:message key="label.no"/></fw:label>
					  </td>
					</tr>
					<tr>
					  <td width="45%" class="moduleLabel" style="padding-top: 15px"><bean-el:message key="label.comms.coveredJun"/>:</td>
					  <td width="55%" class="moduleValue" style="padding-top: 15px">
					  	<c:set var="junYesText"><bean-el:message key="label.comms.coveredJun"/>&nbsp;(<bean-el:message key="label.yes"/>)</c:set>
					  	<c:set var="junNoText"><bean-el:message key="label.comms.coveredJun"/>&nbsp;(<bean-el:message key="label.no"/>)</c:set>
					    <html-el:radio title="${junYesText}" property="coveredJun" value="true" styleId="txtcoveredJun_y" /><fw:label property="coveredJun" forId="txtcoveredJun_y"><bean-el:message key="label.yes"/></fw:label>
					    <html-el:radio title="${junNoText}" property="coveredJun" value="false" styleId="txtcoveredJun_n" /><fw:label property="coveredJun" forId="txtcoveredJun_n"><bean-el:message key="label.no"/></fw:label>
					  </td>
					</tr>
					<tr>
					  <td width="45%" class="moduleLabel" style="padding-top: 15px"><bean-el:message key="label.comms.coveredJul"/>:</td>
					  <td width="55%" class="moduleValue" style="padding-top: 15px">
					  	<c:set var="julYesText"><bean-el:message key="label.comms.coveredJul"/>&nbsp;(<bean-el:message key="label.yes"/>)</c:set>
					  	<c:set var="julNoText"><bean-el:message key="label.comms.coveredJul"/>&nbsp;(<bean-el:message key="label.no"/>)</c:set>
					    <html-el:radio title="${julYesText}" property="coveredJul" value="true" styleId="txtcoveredJul_y" /><fw:label property="coveredJul" forId="txtcoveredJul_y"><bean-el:message key="label.yes"/></fw:label>
					    <html-el:radio title="${julNoText}" property="coveredJul" value="false" styleId="txtcoveredJul_n" /><fw:label property="coveredJul" forId="txtcoveredJul_n"><bean-el:message key="label.no"/></fw:label>
					  </td>
					</tr>
					<tr>
					  <td width="45%" class="moduleLabel" style="padding-top: 15px"><bean-el:message key="label.comms.coveredAug"/>:</td>
					  <td width="55%" class="moduleValue" style="padding-top: 15px">
					  	<c:set var="augYesText"><bean-el:message key="label.comms.coveredAug"/>&nbsp;(<bean-el:message key="label.yes"/>)</c:set>
					  	<c:set var="augNoText"><bean-el:message key="label.comms.coveredAug"/>&nbsp;(<bean-el:message key="label.no"/>)</c:set>
					    <html-el:radio title="${augYesText}" property="coveredAug" value="true" styleId="txtcoveredAug_y" /><fw:label property="coveredAug" forId="txtcoveredAug_y"><bean-el:message key="label.yes"/></fw:label>
					    <html-el:radio title="${augNoText}" property="coveredAug" value="false" styleId="txtcoveredAug_n" /><fw:label property="coveredAug" forId="txtcoveredAug_n"><bean-el:message key="label.no"/></fw:label>
					  </td>
					</tr>
					<tr>
					  <td width="45%" class="moduleLabel" style="padding-top: 15px"><bean-el:message key="label.comms.coveredSep"/>:</td>
					  <td width="55%" class="moduleValue" style="padding-top: 15px">
					  	<c:set var="sepYesText"><bean-el:message key="label.comms.coveredSep"/>&nbsp;(<bean-el:message key="label.yes"/>)</c:set>
					  	<c:set var="sepNoText"><bean-el:message key="label.comms.coveredSep"/>&nbsp;(<bean-el:message key="label.no"/>)</c:set>
					    <html-el:radio title="${sepYesText}" property="coveredSep" value="true" styleId="txtcoveredSep_y" /><fw:label property="coveredSep" forId="txtcoveredSep_y"><bean-el:message key="label.yes"/></fw:label>
					    <html-el:radio title="${sepNoText}" property="coveredSep" value="false" styleId="txtcoveredSep_n" /><fw:label property="coveredSep" forId="txtcoveredSep_n"><bean-el:message key="label.no"/></fw:label>
					  </td>
					</tr>
					<tr>
					  <td width="45%" class="moduleLabel" style="padding-top: 15px"><bean-el:message key="label.comms.coveredOct"/>:</td>
					  <td width="55%" class="moduleValue" style="padding-top: 15px">
					  	<c:set var="octYesText"><bean-el:message key="label.comms.coveredOct"/>&nbsp;(<bean-el:message key="label.yes"/>)</c:set>
					  	<c:set var="octNoText"><bean-el:message key="label.comms.coveredOct"/>&nbsp;(<bean-el:message key="label.no"/>)</c:set>
					    <html-el:radio title="${octYesText}" property="coveredOct" value="true" styleId="txtcoveredOct_y" /><fw:label property="coveredOct" forId="txtcoveredOct_y"><bean-el:message key="label.yes"/></fw:label>
					    <html-el:radio title="${octNoText}" property="coveredOct" value="false" styleId="txtcoveredOct_n" /><fw:label property="coveredOct" forId="txtcoveredOct_n"><bean-el:message key="label.no"/></fw:label>
					  </td>
					</tr>
					<tr>
					  <td width="45%" class="moduleLabel" style="padding-top: 15px"><bean-el:message key="label.comms.coveredNov"/>:</td>
					  <td width="55%" class="moduleValue" style="padding-top: 15px">
					  	<c:set var="novYesText"><bean-el:message key="label.comms.coveredNov"/>&nbsp;(<bean-el:message key="label.yes"/>)</c:set>
					  	<c:set var="novNoText"><bean-el:message key="label.comms.coveredNov"/>&nbsp;(<bean-el:message key="label.no"/>)</c:set>
					    <html-el:radio title="${novYesText}" property="coveredNov" value="true" styleId="txtcoveredNov_y" /><fw:label property="coveredNov" forId="txtcoveredNov_y"><bean-el:message key="label.yes"/></fw:label>
					    <html-el:radio title="${novNoText}" property="coveredNov" value="false" styleId="txtcoveredNov_n" /><fw:label property="coveredNov" forId="txtcoveredNov_n"><bean-el:message key="label.no"/></fw:label>
					  </td>
					</tr>
					<tr>
					  <td width="45%" class="moduleLabel" style="padding-top: 15px"><bean-el:message key="label.comms.coveredDec"/>:</td>
					  <td width="55%" class="moduleValue" style="padding-top: 15px">
					  	<c:set var="decYesText"><bean-el:message key="label.comms.coveredDec"/>&nbsp;(<bean-el:message key="label.yes"/>)</c:set>
					  	<c:set var="decNoText"><bean-el:message key="label.comms.coveredDec"/>&nbsp;(<bean-el:message key="label.no"/>)</c:set>
					    <html-el:radio title="${decYesText}" property="coveredDec" value="true" styleId="txtcoveredDec_y" /><fw:label property="coveredDec" forId="txtcoveredDec_y"><bean-el:message key="label.yes"/></fw:label>
					    <html-el:radio title="${decNoText}" property="coveredDec" value="false" styleId="txtcoveredDec_n" /><fw:label property="coveredDec" forId="txtcoveredDec_n"><bean-el:message key="label.no"/></fw:label>
					  </td>
					</tr>
				</table>
			</td>
        <tr>
          <td>
            <table align="center" width="100%" border="0" cellspacing="0" cellpadding="0" class="moduleShellTableBody">

              <tr><td colspan="2"><img alt="" src="../images/spacer.gif" width="1" height="10"></td></tr>

              <tr>
              <c:if test="${canResubmit == true}">
                <td colspan="2" class="moduleValueButton">
                  <table width="100%" border="0" align="center" cellspacing="0" cellpadding="0">
                    <tr>
                      <td width="40%"><img alt=""  src="../images/spacer.gif"/></td>
                      <td><img alt=""  src="../images/buttonEndLeft.gif"/></td>
                      <td><html-el:submit property="methodName" style="width:50; vertical-align: top;" styleClass="buttonText"><bean-el:message key="button.submitIRS"/></html-el:submit></td>
                      <td><img alt=""  src="../images/buttonEndRight.gif"/></td>
                      <td width="1%"><img alt=""  src="../images/spacer.gif"/></td>
                      <td><img alt=""  src="../images/buttonEndLeft.gif"/></td>
                      <td><html-el:submit property="methodName" style="width:50; vertical-align: top;" styleClass="buttonText"><bean-el:message key="button.cancelIRS"/></html-el:submit></td>
                      <td><img alt=""  src="../images/buttonEndRight.gif"/></td>
                      <td width="50%"><img alt=""  src="../images/spacer.gif"/></td>
                    </tr>
                  </table>
                </td>
                </c:if>
              </tr>
            </table>
          </td>
        </tr>
      </table>
    </td>
  </tr>
</html-el:form>
</table>
<br>


