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<div class="nf-repeater-row nf-item-alternating" id="2_ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_2cd166fb-2a0f-4a1e-bae9-3297c8caae94" style="width: 100%; height: 55px; display: block; visibility: visible; position: relative;" name="2_undefined"><div class="nf-form-input nf-section nf-filler-control nf-filler-highlightonvalidationerror" style="left: 0px; top: 0px; width: 225px; height: 45px; overflow: hidden; z-index: 100;" data-formcontroltypeid="c0a89c70-0781-4bd4-8623-f73675005e03" data-controlid="5c211668-967d-47a4-a66b-2f57c1ad56f4" data-uniqueid="c0a89c70-0781-4bd4-8623-f73675005e03" data-controlname="Date" formcontrolid="5c211668-967d-47a4-a66b-2f57c1ad56f4" data-enabled="True"><div class="nf-filler-control-border"><div class="nf-filler-control-inner"><div title="" style="width: 100%;"><input name="2_ctl00$PlaceHolderMain$formFiller$FormView$ctl134$1f65a353_0d79_4b81_b7c6_787a3ba66bae$ctl00$ctl03$f380ff95_2c2f_49cb_bc87_bf4e09036c87Date" class="nf-date-picker nf-associated-control hasDatepicker" id="2_ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_ctl03_f380ff95_2c2f_49cb_bc87_bf4e09036c87Date" type="text" maxlength="45" value="" formcontrolid="5c211668-967d-47a4-a66b-2f57c1ad56f4"><img width="16" height="15" title="Select a date." class="ui-datepicker-trigger" alt="Select a date." src="/_layouts/15/images/calendar.gif"></div><input name="ctl00$PlaceHolderMain$formFiller$FormView$ctl134$1f65a353_0d79_4b81_b7c6_787a3ba66bae$ctl00$ctl03$ctl02" class="nf-hidden-associated-control" style="visibility: hidden;" type="text" value="" formcontrolid="5c211668-967d-47a4-a66b-2f57c1ad56f4"><span class="nf-validator-error" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_ctl03_ctl03" style="display: none;"></span><span class="nf-validator-error" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_ctl03_ctl04" style="display: none;"></span></div></div></div><div class="nf-form-input nf-section nf-filler-control nf-filler-highlightonvalidationerror" style="left: 225px; top: 0px; width: 95px; height: 45px; overflow: hidden; z-index: 100;" data-formcontroltypeid="c0a89c70-0781-4bd4-8623-f73675005e04" data-controlid="9dfdcd83-58ed-4496-8a9a-4ed23b382210" data-uniqueid="c0a89c70-0781-4bd4-8623-f73675005e04" data-controlname="CHECKBOX_ID" formcontrolid="9dfdcd83-58ed-4496-8a9a-4ed23b382210" data-enabled="True"><div class="nf-filler-control-border"><div class="nf-filler-control-inner"><span class=" nf-associated-control" style="width: 100%; text-align: center; display: inline-block;"><input name="2_ctl00$PlaceHolderMain$formFiller$FormView$ctl134$1f65a353_0d79_4b81_b7c6_787a3ba66bae$ctl00$ctl07$6f2ec3ca_daac_4518_80e7_33d0cc75c516" id="2_ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_ctl07_6f2ec3ca_daac_4518_80e7_33d0cc75c516" type="checkbox" value="on" formcontrolid="9dfdcd83-58ed-4496-8a9a-4ed23b382210"></span></div></div></div><div class="nf-form-input nf-section nf-filler-control nf-filler-highlightonvalidationerror nf-resizable" style="left: 320px; top: 0px; width: 90px; height: 45px; overflow: visible; z-index: 100;" data-formcontroltypeid="c0a89c70-0781-4bd4-8623-f73675005e02" data-controlid="0dfe21e6-55a5-455a-846c-a6d053777190" data-uniqueid="c0a89c70-0781-4bd4-8623-f73675005e02" data-controlname="LIST_ID" formcontrolid="0dfe21e6-55a5-455a-846c-a6d053777190" data-enabled="True" data-currentcontrolvalue="" data-multiselectcontrol="False"><div class="nf-filler-control-border"><div class="nf-filler-control-inner"><div><select name="2_ctl00$PlaceHolderMain$formFiller$FormView$ctl134$1f65a353_0d79_4b81_b7c6_787a3ba66bae$ctl00$ctl11$6059a4dc_689f_4a2f_80a6_50447419feb8" class=" nf-associated-control" id="2_ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_ctl11_6059a4dc_689f_4a2f_80a6_50447419feb8" style="width: 100%;" data-use-attribute-as-value="data-nfChoiceValue" formcontrolid="0dfe21e6-55a5-455a-846c-a6d053777190">
<div class="nf-repeater-row nf-item" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl01_98f3c272-0854-4f10-b119-70aab9e9af1c" style="width: 100%; height: 55px; visibility: visible; position: relative;"><div class="nf-form-input nf-section nf-filler-control nf-filler-highlightonvalidationerror" style="left: 0px; top: 0px; width: 225px; height: 45px; overflow: hidden; z-index: 100;" data-formcontroltypeid="c0a89c70-0781-4bd4-8623-f73675005e03" data-controlid="5c211668-967d-47a4-a66b-2f57c1ad56f4" data-uniqueid="c0a89c70-0781-4bd4-8623-f73675005e03" data-controlname="Date" formcontrolid="5c211668-967d-47a4-a66b-2f57c1ad56f4" data-enabled="True"><div class="nf-filler-control-border"><div class="nf-filler-control-inner"><div title="" style="width: 100%;"><input name="ctl00$PlaceHolderMain$formFiller$FormView$ctl134$1f65a353_0d79_4b81_b7c6_787a3ba66bae$ctl01$ctl03$206f4f22_6df8_450b_b4dd_65871a255806Date" class="nf-date-picker nf-associated-control hasDatepicker" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl01_ctl03_206f4f22_6df8_450b_b4dd_65871a255806Date" type="text" maxlength="45" formcontrolid="5c211668-967d-47a4-a66b-2f57c1ad56f4"><img width="16" height="15" title="Select a date." class="ui-datepicker-trigger" alt="Select a date." src="/_layouts/15/images/calendar.gif"></div><input name="ctl00$PlaceHolderMain$formFiller$FormView$ctl134$1f65a353_0d79_4b81_b7c6_787a3ba66bae$ctl01$ctl03$ctl02" class="nf-hidden-associated-control" style="visibility: hidden;" type="text" formcontrolid="5c211668-967d-47a4-a66b-2f57c1ad56f4"><span class="nf-validator-error" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl01_ctl03_ctl03" style="display: none;"></span><span class="nf-validator-error" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl01_ctl03_ctl04" style="display: none;"></span></div></div></div><div class="nf-form-input nf-section nf-filler-control nf-filler-highlightonvalidationerror" style="left: 225px; top: 0px; width: 95px; height: 45px; overflow: hidden; z-index: 100;" data-formcontroltypeid="c0a89c70-0781-4bd4-8623-f73675005e04" data-controlid="9dfdcd83-58ed-4496-8a9a-4ed23b382210" data-uniqueid="c0a89c70-0781-4bd4-8623-f73675005e04" data-controlname="CHECKBOX_ID" formcontrolid="9dfdcd83-58ed-4496-8a9a-4ed23b382210" data-enabled="True"><div class="nf-filler-control-border"><div class="nf-filler-control-inner"><span class=" nf-associated-control" style="width: 100%; text-align: center; display: inline-block;"><input name="ctl00$PlaceHolderMain$formFiller$FormView$ctl134$1f65a353_0d79_4b81_b7c6_787a3ba66bae$ctl01$ctl07$605ace32_c118_4ea2_9454_92be3e9f6bb6" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl01_ctl07_605ace32_c118_4ea2_9454_92be3e9f6bb6" type="checkbox" formcontrolid="9dfdcd83-58ed-4496-8a9a-4ed23b382210"></span></div></div></div><div class="nf-form-input nf-section nf-filler-control nf-filler-highlightonvalidationerror nf-resizable" style="left: 320px; top: 0px; width: 90px; height: 45px; overflow: visible; z-index: 100;" data-formcontroltypeid="c0a89c70-0781-4bd4-8623-f73675005e02" data-controlid="0dfe21e6-55a5-455a-846c-a6d053777190" data-uniqueid="c0a89c70-0781-4bd4-8623-f73675005e02" data-controlname="LIST_ID" formcontrolid="0dfe21e6-55a5-455a-846c-a6d053777190" data-enabled="True" data-currentcontrolvalue="" data-multiselectcontrol="False"><div class="nf-filler-control-border"><div class="nf-filler-control-inner"><div><select name="ctl00$PlaceHolderMain$formFiller$FormView$ctl134$1f65a353_0d79_4b81_b7c6_787a3ba66bae$ctl01$ctl11$5751a77c_e870_4c81_8e97_86c26732d95c" class=" nf-associated-control" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl01_ctl11_5751a77c_e870_4c81_8e97_86c26732d95c" style="width: 100%;" data-use-attribute-as-value="data-nfChoiceValue" formcontrolid="0dfe21e6-55a5-455a-846c-a6d053777190">
<option value="**SelectValue**" selected=""></option>
<option selected="selected" value="**SelectValue**"></option>
<option value="Claim" data-nfchoicevalue="Claim">Claim</option>
<option value="Claim" data-nfchoicevalue="Claim">Claim</option>
<option value="Provided" data-nfchoicevalue="Provided">Provided</option>
<option value="Provided" data-nfchoicevalue="Provided">Provided</option>
<option value="N/A" data-nfchoicevalue="N/A">N/A</option>
<option value="N/A" data-nfchoicevalue="N/A">N/A</option>


</select></div><span class="nf-validator-error" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_ctl11_ctl03" style="display: none;"></span></div></div></div><div class="nf-form-input nf-section nf-filler-control nf-filler-highlightonvalidationerror nf-resizable" style="left: 410px; top: 0px; width: 90px; height: 45px; overflow: visible; z-index: 100;" data-formcontroltypeid="c0a89c70-0781-4bd4-8623-f73675005e02" data-controlid="9ec1780c-dbf3-4aa0-a2ee-48adf129591e" data-uniqueid="c0a89c70-0781-4bd4-8623-f73675005e02" data-controlname="LIST_ID1" formcontrolid="9ec1780c-dbf3-4aa0-a2ee-48adf129591e" data-enabled="True" data-currentcontrolvalue="" data-multiselectcontrol="False"><div class="nf-filler-control-border"><div class="nf-filler-control-inner"><div><select name="2_ctl00$PlaceHolderMain$formFiller$FormView$ctl134$1f65a353_0d79_4b81_b7c6_787a3ba66bae$ctl00$ctl15$394d2377_cb71_4868_ad4a_2fe67fa3b56e" class=" nf-associated-control" id="2_ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_ctl15_394d2377_cb71_4868_ad4a_2fe67fa3b56e" style="width: 100%;" data-use-attribute-as-value="data-nfChoiceValue" formcontrolid="9ec1780c-dbf3-4aa0-a2ee-48adf129591e">
</select></div><span class="nf-validator-error" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl01_ctl11_ctl03" style="display: none;"></span></div></div></div><div class="nf-form-input nf-section nf-filler-control nf-filler-highlightonvalidationerror nf-resizable" style="left: 410px; top: 0px; width: 90px; height: 45px; overflow: visible; z-index: 100;" data-formcontroltypeid="c0a89c70-0781-4bd4-8623-f73675005e02" data-controlid="9ec1780c-dbf3-4aa0-a2ee-48adf129591e" data-uniqueid="c0a89c70-0781-4bd4-8623-f73675005e02" data-controlname="LIST_ID1" formcontrolid="9ec1780c-dbf3-4aa0-a2ee-48adf129591e" data-enabled="True" data-currentcontrolvalue="" data-multiselectcontrol="False"><div class="nf-filler-control-border"><div class="nf-filler-control-inner"><div><select name="ctl00$PlaceHolderMain$formFiller$FormView$ctl134$1f65a353_0d79_4b81_b7c6_787a3ba66bae$ctl01$ctl15$83421669_dcd1_4c63_be27_08fbf5f86c23" class=" nf-associated-control" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl01_ctl15_83421669_dcd1_4c63_be27_08fbf5f86c23" style="width: 100%;" data-use-attribute-as-value="data-nfChoiceValue" formcontrolid="9ec1780c-dbf3-4aa0-a2ee-48adf129591e">
<option value="**SelectValue**" selected=""></option>
<option selected="selected" value="**SelectValue**"></option>
<option value="Claim" data-nfchoicevalue="Claim">Claim</option>
<option value="Claim" data-nfchoicevalue="Claim">Claim</option>
<option value="Provided" data-nfchoicevalue="Provided">Provided</option>
<option value="Provided" data-nfchoicevalue="Provided">Provided</option>
<option value="N/A" data-nfchoicevalue="N/A">N/A</option>
<option value="N/A" data-nfchoicevalue="N/A">N/A</option>


</select></div><span class="nf-validator-error" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_ctl15_ctl03" style="display: none;"></span></div></div></div><div class="nf-form-input nf-section nf-filler-control nf-filler-highlightonvalidationerror nf-resizable" style="left: 500px; top: 0px; width: 90px; height: 45px; overflow: visible; z-index: 100;" data-formcontroltypeid="c0a89c70-0781-4bd4-8623-f73675005e02" data-controlid="df61360e-8357-4b9d-a2b6-97e0383c3988" data-uniqueid="c0a89c70-0781-4bd4-8623-f73675005e02" data-controlname="LIST_ID2" formcontrolid="df61360e-8357-4b9d-a2b6-97e0383c3988" data-enabled="True" data-currentcontrolvalue="" data-multiselectcontrol="False"><div class="nf-filler-control-border"><div class="nf-filler-control-inner"><div><select name="2_ctl00$PlaceHolderMain$formFiller$FormView$ctl134$1f65a353_0d79_4b81_b7c6_787a3ba66bae$ctl00$ctl19$07cb02c4_909e_482d_8278_5ca5c2c6e20f" class=" nf-associated-control" id="2_ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_ctl19_07cb02c4_909e_482d_8278_5ca5c2c6e20f" style="width: 100%;" data-use-attribute-as-value="data-nfChoiceValue" formcontrolid="df61360e-8357-4b9d-a2b6-97e0383c3988">
</select></div><span class="nf-validator-error" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl01_ctl15_ctl03" style="display: none;"></span></div></div></div><div class="nf-form-input nf-section nf-filler-control nf-filler-highlightonvalidationerror nf-resizable" style="left: 500px; top: 0px; width: 90px; height: 45px; overflow: visible; z-index: 100;" data-formcontroltypeid="c0a89c70-0781-4bd4-8623-f73675005e02" data-controlid="df61360e-8357-4b9d-a2b6-97e0383c3988" data-uniqueid="c0a89c70-0781-4bd4-8623-f73675005e02" data-controlname="LIST_ID2" formcontrolid="df61360e-8357-4b9d-a2b6-97e0383c3988" data-enabled="True" data-currentcontrolvalue="" data-multiselectcontrol="False"><div class="nf-filler-control-border"><div class="nf-filler-control-inner"><div><select name="ctl00$PlaceHolderMain$formFiller$FormView$ctl134$1f65a353_0d79_4b81_b7c6_787a3ba66bae$ctl01$ctl19$b0bc33dc_b83d_4d5e_80e5_bed3414f954d" class=" nf-associated-control" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl01_ctl19_b0bc33dc_b83d_4d5e_80e5_bed3414f954d" style="width: 100%;" data-use-attribute-as-value="data-nfChoiceValue" formcontrolid="df61360e-8357-4b9d-a2b6-97e0383c3988">
<option value="**SelectValue**" selected=""></option>
<option selected="selected" value="**SelectValue**"></option>
<option value="Claim" data-nfchoicevalue="Claim">Claim</option>
<option value="Claim" data-nfchoicevalue="Claim">Claim</option>
<option value="Provided" data-nfchoicevalue="Provided">Provided</option>
<option value="Provided" data-nfchoicevalue="Provided">Provided</option>
<option value="N/A" data-nfchoicevalue="N/A">N/A</option>
<option value="N/A" data-nfchoicevalue="N/A">N/A</option>


</select></div><span class="nf-validator-error" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_ctl19_ctl03" style="display: none;"></span></div></div></div><div class="nf-form-input nf-section. nf-filler-control nf-filler-highlightonvalidationerror" style="left: 590px; top: 0px; width: 105px; height: 45px; overflow: hidden; z-index: 100;" data-formcontroltypeid="c0a89c70-0781-4bd4-8623-f73675005e17" data-controlid="2957a921-2eab-487f-b88b-340755a1bbd0" data-uniqueid="c0a89c70-0781-4bd4-8623-f73675005e17" data-controlname="ClaimAmount" formcontrolid="2957a921-2eab-487f-b88b-340755a1bbd0" data-enabled="True"><div class="nf-filler-control-border"><div class="nf-filler-control-inner"><div title="" class="nf-calculation" style="width: 100%; text-align: right; overflow: hidden;"><label class="nf-calculation-control" style="vertical-align: inherit;">0.00</label><input name="2_ctl00$PlaceHolderMain$formFiller$FormView$ctl134$1f65a353_0d79_4b81_b7c6_787a3ba66bae$ctl00$ctl23$15169abe_b8c5_4df9_b242_cc0a97a7b756" class="nf-calculation-control-value" id="2_ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_ctl23_15169abe_b8c5_4df9_b242_cc0a97a7b756" type="hidden" value="0.00" formcontrolid="2957a921-2eab-487f-b88b-340755a1bbd0" data-type="currency" thousand-separator="0" no-of-decimals="2"></div></div></div></div><img class="nf-repeater-deleterow-image nf-ignore-for-calc" style="padding: 2px;" src="/_layouts/15/NintexForms/images/NF_16x16_RepeaterDeleteRow.png"><input name="2_ctl00$PlaceHolderMain$formFiller$FormView$ctl134$1f65a353_0d79_4b81_b7c6_787a3ba66bae$ctl00$InternalRepeaterRowIndex" class="nf-repeater-serverRowIndex nf-ignore-for-calc" id="2_ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_InternalRepeaterRowIndex" type="hidden" value="2_"><input name="2_ctl00$PlaceHolderMain$formFiller$FormView$ctl134$1f65a353_0d79_4b81_b7c6_787a3ba66bae$ctl00$RepeaterClientRowIndex" class="nf-repeater-clientRowIndex nf-ignore-for-calc" id="2_ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_RepeaterClientRowIndex" type="hidden" value=""><span class="nf-validator-error" id="2_ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_ctl03_f380ff95_2c2f_49cb_bc87_bf4e09036c87Dateval0" style="display: none; visibility: visible;"></span><span class="nf-validator-error" id="2_ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_ctl03_f380ff95_2c2f_49cb_bc87_bf4e09036c87Dateval1" style="display: none; visibility: hidden;"></span><span class="nf-validator-error" id="2_ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_ctl11_6059a4dc_689f_4a2f_80a6_50447419feb8val2" style="display: none; visibility: visible;"></span><span class="nf-validator-error" id="2_ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_ctl15_394d2377_cb71_4868_ad4a_2fe67fa3b56eval3" style="display: none; visibility: visible;"></span><span class="nf-validator-error" id="2_ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl00_ctl19_07cb02c4_909e_482d_8278_5ca5c2c6e20fval4" style="display: none; visibility: visible;"></span></div>
</select></div><span class="nf-validator-error" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl01_ctl19_ctl03" style="display: none;"></span></div></div></div><div class="nf-form-input nf-section. nf-filler-control nf-filler-highlightonvalidationerror" style="left: 590px; top: 0px; width: 105px; height: 45px; overflow: hidden; z-index: 100;" data-formcontroltypeid="c0a89c70-0781-4bd4-8623-f73675005e17" data-controlid="2957a921-2eab-487f-b88b-340755a1bbd0" data-uniqueid="c0a89c70-0781-4bd4-8623-f73675005e17" data-controlname="ClaimAmount" formcontrolid="2957a921-2eab-487f-b88b-340755a1bbd0" data-enabled="True"><div class="nf-filler-control-border"><div class="nf-filler-control-inner"><div title="" class="nf-calculation" style="width: 100%; text-align: right; overflow: hidden;"><label class="nf-calculation-control" style="vertical-align: inherit;">0.00</label><input name="ctl00$PlaceHolderMain$formFiller$FormView$ctl134$1f65a353_0d79_4b81_b7c6_787a3ba66bae$ctl01$ctl23$b30db6af_a1e7_4cae_9175_21b83f9a7928" class="nf-calculation-control-value" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl01_ctl23_b30db6af_a1e7_4cae_9175_21b83f9a7928" type="hidden" value="0.00" formcontrolid="2957a921-2eab-487f-b88b-340755a1bbd0" data-type="currency" thousand-separator="0" no-of-decimals="2"></div></div></div></div><img class="nf-repeater-deleterow-image nf-ignore-for-calc" style="padding: 2px;" src="/_layouts/15/NintexForms/images/NF_16x16_RepeaterDeleteRow.png"><input name="ctl00$PlaceHolderMain$formFiller$FormView$ctl134$1f65a353_0d79_4b81_b7c6_787a3ba66bae$ctl01$InternalRepeaterRowIndex" class="nf-repeater-serverRowIndex nf-ignore-for-calc" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl01_InternalRepeaterRowIndex" type="hidden" value="1"><input name="ctl00$PlaceHolderMain$formFiller$FormView$ctl134$1f65a353_0d79_4b81_b7c6_787a3ba66bae$ctl01$RepeaterClientRowIndex" class="nf-repeater-clientRowIndex nf-ignore-for-calc" id="ctl00_PlaceHolderMain_formFiller_FormView_ctl134_1f65a353_0d79_4b81_b7c6_787a3ba66bae_ctl01_RepeaterClientRowIndex" type="hidden"></div>
已保存差異