@include('dashboard.layouts.header')

<!-- Content Wrapper. Contains page content -->
<div class="content-wrapper">
  <!-- Content Header (Page header) -->
  <section class="content-header">
    <div class="container-fluid">
      <div class="row mb-2">
        <div class="col-sm-6">
          <h1>DBA/Assumed or Fictitious Name Filing</h1>
        </div>
        <div class="col-sm-6">
          <ol class="breadcrumb float-sm-right">
            <li class="breadcrumb-item"><a href="/dashboard">Home</a></li>
            <li class="breadcrumb-item active">DBA/Assumed or Fictitious Name Filing</li>
          </ol>
        </div>
      </div>
    </div><!-- /.container-fluid -->
  </section>

  <!-- Main content -->
  <section class="content">
    <div class="container-fluid">
      <div class="row">
        <!-- left column -->
        <div class="col-md-12">
          <!-- general form elements -->
          <div class="card card-primary">
            <div class="card-header">
              <h3 class="card-title">DBA/Assumed or Fictitious Name Filing</h3>
            </div>
            </br>
            @if (session('success'))
            <div class="alert alert-success">
              {{ session('success') }}
            </div>
            @endif
            @if(isset($report))
            <form action="{{ route('dba-assumed-or-fictitious-name-filing-submit-form.update', $report->id) }}" method="POST" onsubmit="disableButton()">
              @csrf
              @method('PUT')
              @else
              <form action="{{ route('dba-assumed-or-fictitious-name-filing-submit-form') }}" method="POST" onsubmit="disableButton()">
                @csrf
                @endif

                <div class="card-body">
                  <!-- Contact Information -->
                  <h3>Entity Information</h3>
                  <div class="row">
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="entityName">Name of Entity (REAL NAME)</label>
                        <input type="text" value="{{ old('entity_name', $report->entity_name ?? '') }}" class="form-control" name="entity_name" id="entityName" placeholder="Enter entity name">
                        @error('entity_name')
                        <span class="text-danger">{{ $message }}</span>
                        @enderror
                      </div>

                      <div class="form-group">
                        <label for="stateIncorporation">State of Incorporation</label>
                        <input type="text" value="{{ old('state_incorporation', $report->state_incorporation ?? '') }}" class="form-control" name="state_incorporation" id="stateIncorporation" placeholder="Enter state of incorporation">
                      </div>

                      <div class="form-group">
                        <label for="formationDate">Date of Formation</label>
                        <input type="date" value="{{ old('formation_date', $report->formation_date ?? '') }}" class="form-control" name="formation_date" id="formationDate">
                      </div>
                    </div>

                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="entityType">Type of Entity</label>
                        <select class="form-control" name="entity_type" id="entityType">
                          <option value="Corporation" {{ old('entity_type', $report->entity_type ?? '') == 'Corporation' ? 'selected' : '' }}>Corporation</option>
                          <option value="S Corporation" {{ old('entity_type', $report->entity_type ?? '') == 'S Corporation' ? 'selected' : '' }}>S Corporation</option>
                          <option value="Partnership" {{ old('entity_type', $report->entity_type ?? '') == 'Partnership' ? 'selected' : '' }}>Partnership</option>
                          <option value="Single Member LLC" {{ old('entity_type', $report->entity_type ?? '') == 'Single Member LLC' ? 'selected' : '' }}>Single Member LLC</option>
                          <option value="Multi Member LLC" {{ old('entity_type', $report->entity_type ?? '') == 'Multi Member LLC' ? 'selected' : '' }}>Multi Member LLC</option>
                          <option value="Sole Proprietor" {{ old('entity_type', $report->entity_type ?? '') == 'Sole Proprietor' ? 'selected' : '' }}>Sole Proprietor</option>
                        </select>

                        @error('entity_type')
                        <span class="text-danger">{{ $message }}</span>
                        @enderror
                      </div>

                      <div class="form-group">
                        <label for="county">County</label>
                        <input type="text" value="{{ old('county', $report->county ?? '') }}" class="form-control" name="county" id="county" placeholder="Enter county">
                      </div>


                    </div>
                  </div>

                  <div class="form-group">
                    <label for="businessDescription">Business Description</label>
                    <textarea class="form-control" name="business_description" id="businessDescription" rows="4" placeholder="Enter business description">{{ old('business_description', $report->business_description ?? '') }}</textarea>
                  </div>
                  <hr>
                  <h3>Shareholder Information</h3>

                  <div class="row">
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="contactName">Name of Contact Person</label>
                        <input type="text" value="{{ old('contact_name', $report->contact_name ?? '') }}" class="form-control" name="contact_name" id="contactName" placeholder="Enter contact person's name">
                      </div>

                      <div class="form-group">
                        <label for="suite">Suite/Apt</label>
                        <input type="text" value="{{ old('suite', $report->suite ?? '') }}" class="form-control" name="suite" id="suite" placeholder="Enter suite or apartment number">
                      </div>
                      <div class="form-group">
                        <label for="state">State</label>
                        <input type="text" value="{{ old('state', $report->state ?? '') }}" class="form-control" name="state" id="state" placeholder="Enter state">
                      </div>

                      <div class="form-group">
                        <label for="phone">Phone</label>
                        <input type="text" value="{{ old('phone', $report->phone ?? '') }}" class="form-control" name="phone" id="phone" placeholder="(123) 456-7890">
                      </div>

                      <div class="form-group">
                        <label for="email">Email</label>
                        <input type="email" value="{{ old('email', $report->email ?? '') }}" class="form-control" name="email" id="email" placeholder="Enter email">
                      </div>

                    </div>
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="designation">Designation</label>
                        <input type="text" value="{{ old('designation', $report->designation ?? '') }}" class="form-control" name="designation" id="designation" placeholder="Enter designation">
                      </div>
                      <div class="form-group">
                        <label for="city">City</label>
                        <input type="text" value="{{ old('city', $report->city ?? '') }}" class="form-control" name="city" id="city" placeholder="Enter city">
                      </div>

                      <div class="form-group">
                        <label for="zip">Zip</label>
                        <input type="text" value="{{ old('zip', $report->zip ?? '') }}" class="form-control" name="zip" id="zip" placeholder="Enter zip code">
                      </div>

                      <div class="form-group">
                        <label for="fax">Fax</label>
                        <input type="text" value="{{ old('fax', $report->fax ?? '') }}" class="form-control" name="fax" id="fax" placeholder="(123) 456-7890">
                      </div>
                    </div>
                  </div>
                  <div class="form-group">
                    <label for="contactAddress">Address</label>
                    <input type="text" value="{{ old('contact_address', $report->contact_address ?? '') }}" class="form-control" name="contact_address" id="contactAddress" placeholder="Enter address">
                  </div>

                  <h3>Assumed Information</h3>
                  <div class="row">
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="assumedName">Enter the assumed name that you would like to register</label>
                        <input type="text" value="{{ old('assumed_name', $report->assumed_name ?? '') }}" class="form-control" name="assumed_name" id="assumedName" placeholder="Enter assumed name">
                      </div>
                      <div class="form-group">
                        <label for="assumedSuite">Suite/Apt</label>
                        <input type="text" value="{{ old('assumed_suite', $report->assumed_suite ?? '') }}" class="form-control" name="assumed_suite" id="assumedSuite" placeholder="Enter suite or apartment number">
                      </div>
                      <div class="form-group">
                        <label for="assumedCounty">County</label>
                        <input type="text" value="{{ old('assumed_county', $report->assumed_county ?? '') }}" class="form-control" name="assumed_county" id="assumedCounty" placeholder="Enter county">
                      </div>


                    </div>

                    <div class="col-md-6 col-print-6">

                      <div class="form-group">
                        <label for="assumedCity">City</label>
                        <input type="text" value="{{ old('assumed_city', $report->assumed_city ?? '') }}" class="form-control" name="assumed_city" id="assumedCity" placeholder="Enter city">
                      </div>
                      <div class="form-group">
                        <label for="assumedState">State</label>
                        <input type="text" value="{{ old('assumed_state', $report->assumed_state ?? '') }}" class="form-control" name="assumed_state" id="assumedState" placeholder="Enter state">
                      </div>

                      <div class="form-group">
                        <label for="assumedZip">Zip</label>
                        <input type="text" value="{{ old('assumed_zip', $report->assumed_zip ?? '') }}" class="form-control" name="assumed_zip" id="assumedZip" placeholder="Enter zip code">
                      </div>

                    </div>
                  </div>

                  <div class="form-group">
                    <label for="assumedAddress">Enter the address at which you plan to operate under this assumed name</label>
                    <input type="text" value="{{ old('assumed_address', $report->assumed_address ?? '') }}" class="form-control" name="assumed_address" id="assumedAddress" placeholder="Enter address">
                  </div>

                  <div class="form-group">
                    <label>
                      <input type="checkbox" name="authorize_dba" value="1" id="authorizeDba" {{ old('authorize_dba', $report->authorize_dba ?? false) ? 'checked' : '' }}>
                      I authorize ITAXEXPERTS.COM to Apply for Assumed Name filing (DBA) and willing to pay
                    </label>
                    <input type="text" value="{{ old('fee_amount', $report->fee_amount ?? '') }}" class="form-control" name="fee_amount" id="feeAmount" placeholder="Enter fee amount" style="width: 150px; display: inline-block;">
                    (exclusive of State and county Fee)
                  </div>

                  <div class="row">
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="name">Name</label>
                        <input type="text" value="{{ old('name', $report->name ?? '') }}" class="form-control" name="name" id="name" placeholder="Enter your name">
                      </div>
                    </div>
                    <div class="col-md-6 col-print-6">
                      <div class="form-group">
                        <label for="signature">Signature</label>
                        <input type="text" value="{{ old('signature', $report->signature ?? '') }}" class="form-control" name="signature" id="signature" placeholder="Enter your signature">
                      </div>
                    </div>
                  </div>




                  <h3>Credit Card Authorization</h3>
                  <div class="row">
                    <div class="col-md-6 col-print-6">

                      <div class="form-group">
                        <label for="cardType">Card Type</label>
                        <select class="form-control" id="cardType" name="card_type">
                          <option value="Visa" {{ old('card_type', $report->card_type ?? '') == 'Visa' ? 'selected' : '' }}>Visa</option>
                          <option value="MasterCard" {{ old('card_type', $report->card_type ?? '') == 'MasterCard' ? 'selected' : '' }}>MasterCard</option>
                          <option value="American Express" {{ old('card_type', $report->card_type ?? '') == 'American Express' ? 'selected' : '' }}>American Express</option>
                          <option value="Discover" {{ old('card_type', $report->card_type ?? '') == 'Discover' ? 'selected' : '' }}>Discover</option>
                        </select>
                      </div>

                      <div class="form-group">
                        <label for="cardNumber">Credit Card Number</label>
                        <input type="text" value="{{ old('card_number', $report->card_number ?? '') }}" class="form-control" name="card_number" id="cardNumber" placeholder="Enter Credit Card Number">
                      </div>


                      <div class="form-group">
                        <label for="expiryDate">Expiration Date</label>
                        <input type="month" value="{{ old('card_expiration', $report->card_expiration ?? '') }}" class="form-control" name="card_expiration" id="expiryDate">
                      </div>

                      <div class="form-group">
                        <label for="billingCityStateZip">City, State, Zip</label>
                        <input type="text" value="{{ old('billing_city_state_zip', $report->billing_city_state_zip ?? '') }}" class="form-control" name="billing_city_state_zip" id="billingCityStateZip" placeholder="Enter city, state, zip">
                      </div>

                    </div>


                    <div class="col-md-6 col-print-6">

                      <div class="form-group">
                        <label for="cardHolderName">Name on the Credit Card</label>
                        <input type="text" value="{{ old('card_name', $report->card_name ?? '') }}" class="form-control" name="card_name" id="cardHolderName" placeholder="Enter Name on the Credit Card">
                      </div>

                      <div class="form-group">
                        <label for="csvCode">Security (CSV) Code</label>
                        <input type="text" value="{{ old('csv_code', $report->csv_code ?? '') }}" class="form-control" name="csv_code" id="csvCode" placeholder="Enter CSV Code">
                      </div>


                      <!-- Signature -->
                      <div class="form-group">
                        <label for="signature">Signature of Card Holder</label>
                        <input type="text" value="{{ old('signature', $report->signature ?? '') }}" class="form-control" name="signature" id="signature" placeholder="Enter Signature">
                      </div>

                    </div>
                  </div>

                  <div class="form-group">
                    <label for="billingAddress">Billing Address</label>
                    <input type="text" value="{{ old('billing_address', $report->billing_address ?? '') }}" class="form-control" name="billing_address" id="billingAddress" placeholder="Enter Billing Address">
                  </div>
                  <!-- Notes Section -->
                  <div class="form-group">
                    <label for="notes">Notes</label>
                    <textarea class="form-control" name="notes" id="notes" rows="3" placeholder="Enter any notes">{{ old('notes', $report->notes ?? '') }}</textarea>
                  </div>
                  <div class="card-footer">
                    <button type="submit" class="btn btn-primary" id="submitButton">Submit</button>
                  </div>
              </form>

          </div>
        </div>
      </div>
    </div>
  </section>
</div>
@include('dashboard.layouts.footer')

<script>
  function formatUSPhone(input) {

    let value = input.value.replace(/\D/g, ''); // remove non-digits
    if (value.length > 3 && value.length <= 6) {
      input.value = `(${value.slice(0, 3)}) ${value.slice(3)}`;
    } else if (value.length > 6) {
      input.value = `(${value.slice(0, 3)}) ${value.slice(3, 6)}-${value.slice(6, 10)}`;
    } else {
      input.value = value;
    }
  }
  document.addEventListener("DOMContentLoaded", function() {
    document.getElementById('phone').addEventListener('input', function() {
      formatUSPhone(this);
    });
    document.getElementById('fax').addEventListener('input', function() {
      formatUSPhone(this);
    });
    document.getElementById('shareholder1Phone').addEventListener('input', function() {
      formatUSPhone(this);
    });
    document.getElementById('shareholder1Fax').addEventListener('input', function() {
      formatUSPhone(this);
    });
  });
</script>

<script>
  $(function() {
    bsCustomFileInput.init();
  });
</script>
<script>
  function disableButton() {
    let btn = document.getElementById('submitButton');
    btn.disabled = true;
    btn.innerText = 'Submitting...'; // Change button text

    // Allow form submission
    return true;
  }
</script>
</body>

</html>