{
  "Health Care Fund Dependent Enrollment Form": {
    "CCPU PROVIDER": {
      "*First Name": "Emily",
      "Middle Name": "Grace",
      "*Age": "34",
      "*Last Name": "Carter",
      "*Gender": "Female",
      "*Health Care Fund ID U-Number": "784512369",
      "*Birth Date (mm/dd/yyyy)": "06/18/1990",
      "Work Phone": "6465550279",
      "*Home Phone": "2125550184",
      "*E-mail Address": "emily.carter@example.com",
      "*Home Address": "1458 Maple Avenue, Brooklyn, NY 11215",
      "*Country": "United States",
      "*State": "California",
      "*ZIP": "94105",
      "*City": "San Francisco"
    },
    "MAILING ADDRESS (IF DIFFERENT THAN LISTED ABOVE)": {
      "Mailing Address": "123 Market Street, Apt 8B",
      "Country": "United States",
      "ZIP": "94105",
      "State": "California",
      "City": "San Francisco"
    },
    "LIST ALL DEPENDENTS YOU WOULD LIKE TO ADD (ATTACH ADDITIONAL PAGES IF NEEDED)": [
      {
        "*SSN/ITIN": "123-45-6789",
        "*Full Time Student?": "Yes",
        "*Relationship (Spouse/Domestic Partner/Child)": "Spouse",
        "*Gender (M/F)": "F",
        "*Name (Last, first, middle initial)": "Smith, John A.",
        "*Birthdate (mm/dd/yyyy)": "04/18/1986"
      },
      {
        "*SSN/ITIN": "987-65-4321",
        "*Full Time Student?": "No",
        "*Relationship (Spouse/Domestic Partner/Child)": "Child",
        "*Gender (M/F)": "F",
        "*Name (Last, first, middle initial)": "Johnson, Emily R.",
        "*Birthdate (mm/dd/yyyy)": "09/27/1989"
      },
      {
        "*SSN/ITIN": "456-78-9012",
        "*Full Time Student?": "Yes",
        "*Relationship (Spouse/Domestic Partner/Child)": "Child",
        "*Gender (M/F)": "M",
        "*Name (Last, first, middle initial)": "Brown, Michael T.",
        "*Birthdate (mm/dd/yyyy)": "01/12/2012"
      },
      {
        "*SSN/ITIN": "900-70-1234",
        "*Full Time Student?": "Yes",
        "*Relationship (Spouse/Domestic Partner/Child)": "Domestic Partner",
        "*Gender (M/F)": "F",
        "*Name (Last, first, middle initial)": "Davis, Sarah L.",
        "*Birthdate (mm/dd/yyyy)": "06/05/2015"
      },
      {
        "*SSN/ITIN": "900-80-5678",
        "*Full Time Student?": "No",
        "*Relationship (Spouse/Domestic Partner/Child)": "Child",
        "*Gender (M/F)": "M",
        "*Name (Last, first, middle initial)": "Miller, David K.",
        "*Birthdate (mm/dd/yyyy)": "11/23/2018"
      },
      {
        "*SSN/ITIN": "900-90-2468",
        "*Full Time Student?": "No",
        "*Relationship (Spouse/Domestic Partner/Child)": "Child",
        "*Gender (M/F)": "F",
        "*Name (Last, first, middle initial)": "Wilson, Laura M.",
        "*Birthdate (mm/dd/yyyy)": "08/22/2016"
      }
    ]
  }
}