diff --git a/modules/simple_forms_api/app/form_mappings/vba_21_4142.json.erb b/modules/simple_forms_api/app/form_mappings/vba_21_4142.json.erb
index 665eb1d6331..8ff6186c5f9 100644
--- a/modules/simple_forms_api/app/form_mappings/vba_21_4142.json.erb
+++ b/modules/simple_forms_api/app/form_mappings/vba_21_4142.json.erb
@@ -45,106 +45,106 @@
   "F[0].#subform[1].Date_Signed_Day[0]": "<%= Time.current.in_time_zone('America/Chicago').strftime('%d') %>",
   "F[0].#subform[1].Relationship_To_Veteran_Claimant[0]": "<%= form.data.dig('preparer_identification', 'relationship_to_veteran') || form.data.dig('preparer_identification', 'other') %> <%= form.data.dig('preparer_identification', 'preparer_full_name', 'first') %> <%= form.data.dig('preparer_identification', 'preparer_full_name', 'middle') %> <%= form.data.dig('preparer_identification', 'preparer_full_name', 'last') %> <%= form.data.dig('preparer_identification', 'preparer_title') %> <%= form.data.dig('preparer_identification', 'preparer_organization') %> <%= form.data.dig('preparer_identification', 'preparer_address', 'street') %> <%= form.data.dig('preparer_identification', 'preparer_address', 'street2') %> <%= form.data.dig('preparer_identification', 'preparer_address', 'city') %> <%= form.data.dig('preparer_identification', 'preparer_address', 'state') %> <%= form.data.dig('preparer_identification', 'preparer_address', 'postal_code') %> <%= form.data.dig('preparer_identification', 'court_appointment_info') %>",
   "F[0].#subform[1].SignatureField11[0]": "<%= form.data.dig('veteran', 'full_name', 'first') %> <%= form.data.dig('veteran', 'full_name', 'middle') %> <%= form.data.dig('veteran', 'full_name', 'last') %>",
-  "F[0].#subform[9].VeteranFirstName[0]": "<%= form.data.dig('veteran', 'full_name', 'first') %>",
-  "F[0].#subform[9].VeteranMiddleInitial1[0]": "<%= form.data.dig('veteran', 'full_name', 'middle') %>",
-  "F[0].#subform[9].VeteranLastName[0]": "<%= form.data.dig('veteran', 'full_name', 'last') %>",
-  "F[0].#subform[9].VAFileNumber[0]": "<%= form.data.dig('veteran', 'va_file_number') %>",
-  "F[0].#subform[9].VeteransServiceNumber_If_Applicable[0]": "<%= form.data.dig('veteran', 'veteran_service_number') %>",
+  "F[0].#subform[14].VeteranFirstName[0]": "<%= form.data.dig('veteran', 'full_name', 'first') %>",
+  "F[0].#subform[14].VeteranMiddleInitial1[0]": "<%= form.data.dig('veteran', 'full_name', 'middle') %>",
+  "F[0].#subform[14].VeteranLastName[0]": "<%= form.data.dig('veteran', 'full_name', 'last') %>",
+  "F[0].#subform[14].VAFileNumber[0]": "<%= form.data.dig('veteran', 'va_file_number') %>",
+  "F[0].#subform[14].VeteransServiceNumber_If_Applicable[0]": "<%= form.data.dig('veteran', 'veteran_service_number') %>",
 
-  "F[0].#subform[9].Patients_FirstName[0]": "<%= form.data.dig('patient_identification', 'patient_full_name', 'first') %>",
-  "F[0].#subform[9].PatientMiddleInitial1[0]": "<%= form.data.dig('patient_identification', 'patient_full_name', 'middle') %>",
-  "F[0].#subform[9].Patients_LastName[0]": "<%= form.data.dig('patient_identification', 'patient_full_name', 'last') %>",
-  "F[0].#subform[9].Provider_Or_Facility_Name[0]": "<%= form.data['provider_facility'][0]&.dig('provider_facility_name') %>",
-  "F[0].#subform[9].Provider_Facility_Address_ZIPOrPostalCode_FirstFiveNumbers[0]": "<%= form.data['provider_facility'][0]&.dig('provider_facility_address', 'postal_code')&.[](0..4) %>",
-  "F[0].#subform[9].Provider_Facility_Address_ZIPOrPostalCode_LastFourNumbers[0]": "<%= form.data['provider_facility'][0]&.dig('provider_facility_address', 'postal_code')&.[](5..8) %>",
-  "F[0].#subform[9].Provider_Facility_Address_Country[0]": "<%= form.data['provider_facility'][0]&.dig('provider_facility_address', 'country') %>",
-  "F[0].#subform[9].Provider_Facility_Address_StateOrProvince[0]": "<%= form.data['provider_facility'][0]&.dig('provider_facility_address', 'state') %>",
-  "F[0].#subform[9].Provider_Facility_Address_City[0]": "<%= form.data['provider_facility'][0]&.dig('provider_facility_address', 'city') %>",
-  "F[0].#subform[9].MailingAddress_ApartmentOrUnitNumber[0]": "<%= form.data['provider_facility'][0]&.dig('provider_facility_address', 'street2')&.gsub(/\D/, '') %>",
-  "F[0].#subform[9].Provider_Facility_Street_Address_NumberAndStreet[0]": "<%= form.data['provider_facility'][0]&.dig('provider_facility_address', 'street') %>",
-  "F[0].#subform[9].PatientsSocialSecurityNumber_FirstThreeNumbers[0]": "<%= form.data.dig('patient_identification', 'patient_ssn')&.[](0..2) %>",
-  "F[0].#subform[9].PatientsSocialSecurityNumber_SecondTwoNumbers[0]": "<%= form.data.dig('patient_identification', 'patient_ssn')&.[](3..4) %>",
-  "F[0].#subform[9].PatientsSocialSecurityNumber_LastFourNumbers[0]": "<%= form.data.dig('patient_identification', 'patient_ssn')&.[](5..8) %>",
-  "F[0].#subform[9].VeteransSocialSecurityNumber_FirstThreeNumbers[1]": "<%= form.data.dig('veteran', 'ssn')&.[](0..2) %>",
-  "F[0].#subform[9].VeteransSocialSecurityNumber_SecondTwoNumbers[1]": "<%= form.data.dig('veteran', 'ssn')&.[](3..4) %>",
-  "F[0].#subform[9].VeteransSocialSecurityNumber_LastFourNumbers[1]": "<%= form.data.dig('veteran', 'ssn')&.[](5..8) %>",
-  "F[0].#subform[9].DOB_Year[0]": "<%= form.data.dig('veteran', 'date_of_birth')&.[](0..3) %>",
-  "F[0].#subform[9].DOB_Month[0]": "<%= form.data.dig('veteran', 'date_of_birth')&.[](5..6) %>",
-  "F[0].#subform[9].DOB_Day[0]": "<%= form.data.dig('veteran', 'date_of_birth')&.[](8..9) %>",
-  "F[0].#subform[9].FromDate_Year[0]": "<%= form.data['provider_facility'][0]&.dig('treatment_date_range', 'from')&.[](0..3) %>",
-  "F[0].#subform[9].FromDate_Month[0]": "<%= form.data['provider_facility'][0]&.dig('treatment_date_range', 'from')&.[](5..6) %>",
-  "F[0].#subform[9].FromDate_Day[0]": "<%= form.data['provider_facility'][0]&.dig('treatment_date_range', 'from')&.[](8..9) %>",
-  "F[0].#subform[9].ToDate_Year[0]": "<%= form.data['provider_facility'][0]&.dig('treatment_date_range', 'to')&.[](0..3) %>",
-  "F[0].#subform[9].ToDate_Month[0]": "<%= form.data['provider_facility'][0]&.dig('treatment_date_range', 'to')&.[](5..6) %>",
-  "F[0].#subform[9].ToDate_Day[0]": "<%= form.data['provider_facility'][0]&.dig('treatment_date_range', 'to')&.[](8..9) %>",
-  "F[0].#subform[9].VAFileNumber[1]": "<%= form.data.dig('patient_identification', 'patient_va_file_number') %>",
-  "F[0].#subform[9].Conditions_You_Are_Being_Treated_For[0]": "<%= form.data['provider_facility'][0]&.dig('conditions_treated') %>",
+  "F[0].#subform[14].Patients_FirstName[0]": "<%= form.data.dig('patient_identification', 'patient_full_name', 'first') %>",
+  "F[0].#subform[14].PatientMiddleInitial1[0]": "<%= form.data.dig('patient_identification', 'patient_full_name', 'middle') %>",
+  "F[0].#subform[14].Patients_LastName[0]": "<%= form.data.dig('patient_identification', 'patient_full_name', 'last') %>",
+  "F[0].#subform[14].Provider_Or_Facility_Name[0]": "<%= form.data['provider_facility'][0]&.dig('provider_facility_name') %>",
+  "F[0].#subform[14].Provider_Facility_Address_ZIPOrPostalCode_FirstFiveNumbers[0]": "<%= form.data['provider_facility'][0]&.dig('provider_facility_address', 'postal_code')&.[](0..4) %>",
+  "F[0].#subform[14].Provider_Facility_Address_ZIPOrPostalCode_LastFourNumbers[0]": "<%= form.data['provider_facility'][0]&.dig('provider_facility_address', 'postal_code')&.[](5..8) %>",
+  "F[0].#subform[14].Provider_Facility_Address_Country[0]": "<%= form.data['provider_facility'][0]&.dig('provider_facility_address', 'country') %>",
+  "F[0].#subform[14].Provider_Facility_Address_StateOrProvince[0]": "<%= form.data['provider_facility'][0]&.dig('provider_facility_address', 'state') %>",
+  "F[0].#subform[14].Provider_Facility_Address_City[0]": "<%= form.data['provider_facility'][0]&.dig('provider_facility_address', 'city') %>",
+  "F[0].#subform[14].MailingAddress_ApartmentOrUnitNumber[0]": "<%= form.data['provider_facility'][0]&.dig('provider_facility_address', 'street2')&.gsub(/\D/, '') %>",
+  "F[0].#subform[14].Provider_Facility_Street_Address_NumberAndStreet[0]": "<%= form.data['provider_facility'][0]&.dig('provider_facility_address', 'street') %>",
+  "F[0].#subform[14].PatientsSocialSecurityNumber_FirstThreeNumbers[0]": "<%= form.data.dig('patient_identification', 'patient_ssn')&.[](0..2) %>",
+  "F[0].#subform[14].PatientsSocialSecurityNumber_SecondTwoNumbers[0]": "<%= form.data.dig('patient_identification', 'patient_ssn')&.[](3..4) %>",
+  "F[0].#subform[14].PatientsSocialSecurityNumber_LastFourNumbers[0]": "<%= form.data.dig('patient_identification', 'patient_ssn')&.[](5..8) %>",
+  "F[0].#subform[14].VeteransSocialSecurityNumber_FirstThreeNumbers[1]": "<%= form.data.dig('veteran', 'ssn')&.[](0..2) %>",
+  "F[0].#subform[14].VeteransSocialSecurityNumber_SecondTwoNumbers[1]": "<%= form.data.dig('veteran', 'ssn')&.[](3..4) %>",
+  "F[0].#subform[14].VeteransSocialSecurityNumber_LastFourNumbers[1]": "<%= form.data.dig('veteran', 'ssn')&.[](5..8) %>",
+  "F[0].#subform[14].DOB_Year[0]": "<%= form.data.dig('veteran', 'date_of_birth')&.[](0..3) %>",
+  "F[0].#subform[14].DOB_Month[0]": "<%= form.data.dig('veteran', 'date_of_birth')&.[](5..6) %>",
+  "F[0].#subform[14].DOB_Day[0]": "<%= form.data.dig('veteran', 'date_of_birth')&.[](8..9) %>",
+  "F[0].#subform[14].FromDate_Year[0]": "<%= form.data['provider_facility'][0]&.dig('treatment_date_range', 'from')&.[](0..3) %>",
+  "F[0].#subform[14].FromDate_Month[0]": "<%= form.data['provider_facility'][0]&.dig('treatment_date_range', 'from')&.[](5..6) %>",
+  "F[0].#subform[14].FromDate_Day[0]": "<%= form.data['provider_facility'][0]&.dig('treatment_date_range', 'from')&.[](8..9) %>",
+  "F[0].#subform[14].ToDate_Year[0]": "<%= form.data['provider_facility'][0]&.dig('treatment_date_range', 'to')&.[](0..3) %>",
+  "F[0].#subform[14].ToDate_Month[0]": "<%= form.data['provider_facility'][0]&.dig('treatment_date_range', 'to')&.[](5..6) %>",
+  "F[0].#subform[14].ToDate_Day[0]": "<%= form.data['provider_facility'][0]&.dig('treatment_date_range', 'to')&.[](8..9) %>",
+  "F[0].#subform[14].VAFileNumber[1]": "<%= form.data.dig('patient_identification', 'patient_va_file_number') %>",
+  "F[0].#subform[14].Conditions_You_Are_Being_Treated_For[0]": "<%= form.data['provider_facility'][0]&.dig('conditions_treated') %>",
 
-  "F[0].#subform[9].Provider_Or_Facility_Name[1]": "<%= form.data['provider_facility'][1]&.dig('provider_facility_name') %>",
-  "F[0].#subform[9].Provider_Facility_Address_ZIPOrPostalCode_FirstFiveNumbers[1]": "<%= form.data['provider_facility'][1]&.dig('provider_facility_address', 'postal_code')&.[](0..4) %>",
-  "F[0].#subform[9].Provider_Facility_Address_ZIPOrPostalCode_LastFourNumbers[1]": "<%= form.data['provider_facility'][1]&.dig('provider_facility_address', 'postal_code')&.[](5..8) %>",
-  "F[0].#subform[9].Provider_Facility_Address_Country[1]": "<%= form.data['provider_facility'][1]&.dig('provider_facility_address', 'country') %>",
-  "F[0].#subform[9].Provider_Facility_Address_StateOrProvince[1]": "<%= form.data['provider_facility'][1]&.dig('provider_facility_address', 'state') %>",
-  "F[0].#subform[9].Provider_Facility_Address_City[1]": "<%= form.data['provider_facility'][1]&.dig('provider_facility_address', 'city') %>",
-  "F[0].#subform[9].MailingAddress_ApartmentOrUnitNumber[1]": "<%= form.data['provider_facility'][1]&.dig('provider_facility_address', 'street2')&.gsub(/\D/, '') %>",
-  "F[0].#subform[9].Provider_Facility_Street_Address_NumberAndStreet[1]": "<%= form.data['provider_facility'][1]&.dig('provider_facility_address', 'street') %>",
-  "F[0].#subform[9].FromDate_Year[1]": "<%= form.data['provider_facility'][1]&.dig('treatment_date_range', 'from')&.[](0..3) %>",
-  "F[0].#subform[9].FromDate_Month[1]": "<%= form.data['provider_facility'][1]&.dig('treatment_date_range', 'from')&.[](5..6) %>",
-  "F[0].#subform[9].FromDate_Day[1]": "<%= form.data['provider_facility'][1]&.dig('treatment_date_range', 'from')&.[](8..9) %>",
-  "F[0].#subform[9].ToDate_Year[1]": "<%= form.data['provider_facility'][1]&.dig('treatment_date_range', 'to')&.[](0..3) %>",
-  "F[0].#subform[9].ToDate_Month[1]": "<%= form.data['provider_facility'][1]&.dig('treatment_date_range', 'to')&.[](5..6) %>",
-  "F[0].#subform[9].ToDate_Day[1]": "<%= form.data['provider_facility'][1]&.dig('treatment_date_range', 'to')&.[](8..9) %>",
-  "F[0].#subform[9].Conditions_You_Are_Being_Treated_For[1]": "<%= form.data['provider_facility'][1]&.dig('conditions_treated') %>",
+  "F[0].#subform[14].Provider_Or_Facility_Name[1]": "<%= form.data['provider_facility'][1]&.dig('provider_facility_name') %>",
+  "F[0].#subform[14].Provider_Facility_Address_ZIPOrPostalCode_FirstFiveNumbers[1]": "<%= form.data['provider_facility'][1]&.dig('provider_facility_address', 'postal_code')&.[](0..4) %>",
+  "F[0].#subform[14].Provider_Facility_Address_ZIPOrPostalCode_LastFourNumbers[1]": "<%= form.data['provider_facility'][1]&.dig('provider_facility_address', 'postal_code')&.[](5..8) %>",
+  "F[0].#subform[14].Provider_Facility_Address_Country[1]": "<%= form.data['provider_facility'][1]&.dig('provider_facility_address', 'country') %>",
+  "F[0].#subform[14].Provider_Facility_Address_StateOrProvince[1]": "<%= form.data['provider_facility'][1]&.dig('provider_facility_address', 'state') %>",
+  "F[0].#subform[14].Provider_Facility_Address_City[1]": "<%= form.data['provider_facility'][1]&.dig('provider_facility_address', 'city') %>",
+  "F[0].#subform[14].MailingAddress_ApartmentOrUnitNumber[1]": "<%= form.data['provider_facility'][1]&.dig('provider_facility_address', 'street2')&.gsub(/\D/, '') %>",
+  "F[0].#subform[14].Provider_Facility_Street_Address_NumberAndStreet[1]": "<%= form.data['provider_facility'][1]&.dig('provider_facility_address', 'street') %>",
+  "F[0].#subform[14].FromDate_Year[1]": "<%= form.data['provider_facility'][1]&.dig('treatment_date_range', 'from')&.[](0..3) %>",
+  "F[0].#subform[14].FromDate_Month[1]": "<%= form.data['provider_facility'][1]&.dig('treatment_date_range', 'from')&.[](5..6) %>",
+  "F[0].#subform[14].FromDate_Day[1]": "<%= form.data['provider_facility'][1]&.dig('treatment_date_range', 'from')&.[](8..9) %>",
+  "F[0].#subform[14].ToDate_Year[1]": "<%= form.data['provider_facility'][1]&.dig('treatment_date_range', 'to')&.[](0..3) %>",
+  "F[0].#subform[14].ToDate_Month[1]": "<%= form.data['provider_facility'][1]&.dig('treatment_date_range', 'to')&.[](5..6) %>",
+  "F[0].#subform[14].ToDate_Day[1]": "<%= form.data['provider_facility'][1]&.dig('treatment_date_range', 'to')&.[](8..9) %>",
+  "F[0].#subform[14].Conditions_You_Are_Being_Treated_For[1]": "<%= form.data['provider_facility'][1]&.dig('conditions_treated') %>",
 
-  "F[0].#subform[10].Provider_Or_Facility_Name[2]": "<%= form.data['provider_facility'][2]&.dig('provider_facility_name') %>",
-  "F[0].#subform[10].VeteransSocialSecurityNumber_FirstThreeNumbers[2]": "<%= form.data.dig('veteran', 'ssn')&.[](0..2) %>",
-  "F[0].#subform[10].VeteransSocialSecurityNumber_SecondTwoNumbers[2]": "<%= form.data.dig('veteran', 'ssn')&.[](3..4) %>",
-  "F[0].#subform[10].VeteransSocialSecurityNumber_LastFourNumbers[2]": "<%= form.data.dig('veteran', 'ssn')&.[](5..8) %>",
-  "F[0].#subform[10].Provider_Facility_Address_ZIPOrPostalCode_FirstFiveNumbers[2]": "<%= form.data['provider_facility'][2]&.dig('provider_facility_address', 'postal_code')&.[](0..4) %>",
-  "F[0].#subform[10].Provider_Facility_Address_ZIPOrPostalCode_LastFourNumbers[2]": "<%= form.data['provider_facility'][2]&.dig('provider_facility_address', 'postal_code')&.[](5..8) %>",
-  "F[0].#subform[10].Provider_Facility_Address_Country[2]": "<%= form.data['provider_facility'][2]&.dig('provider_facility_address', 'country') %>",
-  "F[0].#subform[10].Provider_Facility_Address_StateOrProvince[2]": "<%= form.data['provider_facility'][2]&.dig('provider_facility_address', 'state') %>",
-  "F[0].#subform[10].Provider_Facility_Address_City[2]": "<%= form.data['provider_facility'][2]&.dig('provider_facility_address', 'city') %>",
-  "F[0].#subform[10].MailingAddress_ApartmentOrUnitNumber[2]": "<%= form.data['provider_facility'][2]&.dig('provider_facility_address', 'street2')&.gsub(/\D/, '') %>",
-  "F[0].#subform[10].Provider_Facility_Street_Address_NumberAndStreet[2]": "<%= form.data['provider_facility'][2]&.dig('provider_facility_address', 'street') %>",
-  "F[0].#subform[10].FromDate_Year[2]": "<%= form.data['provider_facility'][2]&.dig('treatment_date_range', 'from')&.[](0..3) %>",
-  "F[0].#subform[10].FromDate_Month[2]": "<%= form.data['provider_facility'][2]&.dig('treatment_date_range', 'from')&.[](5..6) %>",
-  "F[0].#subform[10].FromDate_Day[2]": "<%= form.data['provider_facility'][2]&.dig('treatment_date_range', 'from')&.[](8..9) %>",
-  "F[0].#subform[10].ToDate_Year[2]": "<%= form.data['provider_facility'][2]&.dig('treatment_date_range', 'to')&.[](0..3) %>",
-  "F[0].#subform[10].ToDate_Month[2]": "<%= form.data['provider_facility'][2]&.dig('treatment_date_range', 'to')&.[](5..6) %>",
-  "F[0].#subform[10].ToDate_Day[2]": "<%= form.data['provider_facility'][2]&.dig('treatment_date_range', 'to')&.[](8..9) %>",
-  "F[0].#subform[10].Conditions_You_Are_Being_Treated_For[2]": "<%= form.data['provider_facility'][2]&.dig('conditions_treated') %>",
+  "F[0].#subform[15].Provider_Or_Facility_Name[2]": "<%= form.data['provider_facility'][2]&.dig('provider_facility_name') %>",
+  "F[0].#subform[15].VeteransSocialSecurityNumber_FirstThreeNumbers[2]": "<%= form.data.dig('veteran', 'ssn')&.[](0..2) %>",
+  "F[0].#subform[15].VeteransSocialSecurityNumber_SecondTwoNumbers[2]": "<%= form.data.dig('veteran', 'ssn')&.[](3..4) %>",
+  "F[0].#subform[15].VeteransSocialSecurityNumber_LastFourNumbers[2]": "<%= form.data.dig('veteran', 'ssn')&.[](5..8) %>",
+  "F[0].#subform[15].Provider_Facility_Address_ZIPOrPostalCode_FirstFiveNumbers[2]": "<%= form.data['provider_facility'][2]&.dig('provider_facility_address', 'postal_code')&.[](0..4) %>",
+  "F[0].#subform[15].Provider_Facility_Address_ZIPOrPostalCode_LastFourNumbers[2]": "<%= form.data['provider_facility'][2]&.dig('provider_facility_address', 'postal_code')&.[](5..8) %>",
+  "F[0].#subform[15].Provider_Facility_Address_Country[2]": "<%= form.data['provider_facility'][2]&.dig('provider_facility_address', 'country') %>",
+  "F[0].#subform[15].Provider_Facility_Address_StateOrProvince[2]": "<%= form.data['provider_facility'][2]&.dig('provider_facility_address', 'state') %>",
+  "F[0].#subform[15].Provider_Facility_Address_City[2]": "<%= form.data['provider_facility'][2]&.dig('provider_facility_address', 'city') %>",
+  "F[0].#subform[15].MailingAddress_ApartmentOrUnitNumber[2]": "<%= form.data['provider_facility'][2]&.dig('provider_facility_address', 'street2')&.gsub(/\D/, '') %>",
+  "F[0].#subform[15].Provider_Facility_Street_Address_NumberAndStreet[2]": "<%= form.data['provider_facility'][2]&.dig('provider_facility_address', 'street') %>",
+  "F[0].#subform[15].FromDate_Year[2]": "<%= form.data['provider_facility'][2]&.dig('treatment_date_range', 'from')&.[](0..3) %>",
+  "F[0].#subform[15].FromDate_Month[2]": "<%= form.data['provider_facility'][2]&.dig('treatment_date_range', 'from')&.[](5..6) %>",
+  "F[0].#subform[15].FromDate_Day[2]": "<%= form.data['provider_facility'][2]&.dig('treatment_date_range', 'from')&.[](8..9) %>",
+  "F[0].#subform[15].ToDate_Year[2]": "<%= form.data['provider_facility'][2]&.dig('treatment_date_range', 'to')&.[](0..3) %>",
+  "F[0].#subform[15].ToDate_Month[2]": "<%= form.data['provider_facility'][2]&.dig('treatment_date_range', 'to')&.[](5..6) %>",
+  "F[0].#subform[15].ToDate_Day[2]": "<%= form.data['provider_facility'][2]&.dig('treatment_date_range', 'to')&.[](8..9) %>",
+  "F[0].#subform[15].Conditions_You_Are_Being_Treated_For[2]": "<%= form.data['provider_facility'][2]&.dig('conditions_treated') %>",
 
-  "F[0].#subform[10].Provider_Or_Facility_Name[3]": "<%= form.data['provider_facility'][3]&.dig('provider_facility_name') %>",
-  "F[0].#subform[10].Provider_Facility_Address_ZIPOrPostalCode_FirstFiveNumbers[3]": "<%= form.data['provider_facility'][3]&.dig('provider_facility_address', 'postal_code')&.[](0..4) %>",
-  "F[0].#subform[10].Provider_Facility_Address_ZIPOrPostalCode_LastFourNumbers[3]": "<%= form.data['provider_facility'][3]&.dig('provider_facility_address', 'postal_code')&.[](5..8) %>",
-  "F[0].#subform[10].Provider_Facility_Address_Country[3]": "<%= form.data['provider_facility'][3]&.dig('provider_facility_address', 'country') %>",
-  "F[0].#subform[10].Provider_Facility_Address_StateOrProvince[3]": "<%= form.data['provider_facility'][3]&.dig('provider_facility_address', 'state') %>",
-  "F[0].#subform[10].Provider_Facility_Address_City[3]": "<%= form.data['provider_facility'][3]&.dig('provider_facility_address', 'city') %>",
-  "F[0].#subform[10].MailingAddress_ApartmentOrUnitNumber[3]": "<%= form.data['provider_facility'][3]&.dig('provider_facility_address', 'street2')&.gsub(/\D/, '') %>",
-  "F[0].#subform[10].Provider_Facility_Street_Address_NumberAndStreet[3]": "<%= form.data['provider_facility'][3]&.dig('provider_facility_address', 'street') %>",
-  "F[0].#subform[10].FromDate_Year[3]": "<%= form.data['provider_facility'][3]&.dig('treatment_date_range', 'from')&.[](0..3) %>",
-  "F[0].#subform[10].FromDate_Month[3]": "<%= form.data['provider_facility'][3]&.dig('treatment_date_range', 'from')&.[](5..6) %>",
-  "F[0].#subform[10].FromDate_Day[3]": "<%= form.data['provider_facility'][3]&.dig('treatment_date_range', 'from')&.[](8..9) %>",
-  "F[0].#subform[10].ToDate_Year[3]": "<%= form.data['provider_facility'][3]&.dig('treatment_date_range', 'to')&.[](0..3) %>",
-  "F[0].#subform[10].ToDate_Month[3]": "<%= form.data['provider_facility'][3]&.dig('treatment_date_range', 'to')&.[](5..6) %>",
-  "F[0].#subform[10].ToDate_Day[3]": "<%= form.data['provider_facility'][3]&.dig('treatment_date_range', 'to')&.[](8..9) %>",
-  "F[0].#subform[10].Conditions_You_Are_Being_Treated_For[3]": "<%= form.data['provider_facility'][3]&.dig('conditions_treated') %>",
+  "F[0].#subform[15].Provider_Or_Facility_Name[3]": "<%= form.data['provider_facility'][3]&.dig('provider_facility_name') %>",
+  "F[0].#subform[15].Provider_Facility_Address_ZIPOrPostalCode_FirstFiveNumbers[3]": "<%= form.data['provider_facility'][3]&.dig('provider_facility_address', 'postal_code')&.[](0..4) %>",
+  "F[0].#subform[15].Provider_Facility_Address_ZIPOrPostalCode_LastFourNumbers[3]": "<%= form.data['provider_facility'][3]&.dig('provider_facility_address', 'postal_code')&.[](5..8) %>",
+  "F[0].#subform[15].Provider_Facility_Address_Country[3]": "<%= form.data['provider_facility'][3]&.dig('provider_facility_address', 'country') %>",
+  "F[0].#subform[15].Provider_Facility_Address_StateOrProvince[3]": "<%= form.data['provider_facility'][3]&.dig('provider_facility_address', 'state') %>",
+  "F[0].#subform[15].Provider_Facility_Address_City[3]": "<%= form.data['provider_facility'][3]&.dig('provider_facility_address', 'city') %>",
+  "F[0].#subform[15].MailingAddress_ApartmentOrUnitNumber[3]": "<%= form.data['provider_facility'][3]&.dig('provider_facility_address', 'street2')&.gsub(/\D/, '') %>",
+  "F[0].#subform[15].Provider_Facility_Street_Address_NumberAndStreet[3]": "<%= form.data['provider_facility'][3]&.dig('provider_facility_address', 'street') %>",
+  "F[0].#subform[15].FromDate_Year[3]": "<%= form.data['provider_facility'][3]&.dig('treatment_date_range', 'from')&.[](0..3) %>",
+  "F[0].#subform[15].FromDate_Month[3]": "<%= form.data['provider_facility'][3]&.dig('treatment_date_range', 'from')&.[](5..6) %>",
+  "F[0].#subform[15].FromDate_Day[3]": "<%= form.data['provider_facility'][3]&.dig('treatment_date_range', 'from')&.[](8..9) %>",
+  "F[0].#subform[15].ToDate_Year[3]": "<%= form.data['provider_facility'][3]&.dig('treatment_date_range', 'to')&.[](0..3) %>",
+  "F[0].#subform[15].ToDate_Month[3]": "<%= form.data['provider_facility'][3]&.dig('treatment_date_range', 'to')&.[](5..6) %>",
+  "F[0].#subform[15].ToDate_Day[3]": "<%= form.data['provider_facility'][3]&.dig('treatment_date_range', 'to')&.[](8..9) %>",
+  "F[0].#subform[15].Conditions_You_Are_Being_Treated_For[3]": "<%= form.data['provider_facility'][3]&.dig('conditions_treated') %>",
 
-  "F[0].#subform[10].Provider_Or_Facility_Name[4]": "<%= form.data['provider_facility'][4]&.dig('provider_facility_name') %>",
-  "F[0].#subform[10].Provider_Facility_Address_ZIPOrPostalCode_FirstFiveNumbers[4]": "<%= form.data['provider_facility'][4]&.dig('provider_facility_address', 'postal_code')&.[](0..4) %>",
-  "F[0].#subform[10].Provider_Facility_Address_ZIPOrPostalCode_LastFourNumbers[4]": "<%= form.data['provider_facility'][4]&.dig('provider_facility_address', 'postal_code')&.[](5..8) %>",
-  "F[0].#subform[10].Provider_Facility_Address_Country[4]": "<%= form.data['provider_facility'][4]&.dig('provider_facility_address', 'country') %>",
-  "F[0].#subform[10].Provider_Facility_Address_StateOrProvince[4]": "<%= form.data['provider_facility'][4]&.dig('provider_facility_address', 'state') %>",
-  "F[0].#subform[10].Provider_Facility_Address_City[4]": "<%= form.data['provider_facility'][4]&.dig('provider_facility_address', 'city') %>",
-  "F[0].#subform[10].MailingAddress_ApartmentOrUnitNumber[4]": "<%= form.data['provider_facility'][4]&.dig('provider_facility_address', 'street2')&.gsub(/\D/, '') %>",
-  "F[0].#subform[10].Provider_Facility_Street_Address_NumberAndStreet[4]": "<%= form.data['provider_facility'][4]&.dig('provider_facility_address', 'street') %>",
-  "F[0].#subform[10].FromDate_Year[4]": "<%= form.data['provider_facility'][4]&.dig('treatment_date_range', 'from')&.[](0..3) %>",
-  "F[0].#subform[10].FromDate_Month[4]": "<%= form.data['provider_facility'][4]&.dig('treatment_date_range', 'from')&.[](5..6) %>",
-  "F[0].#subform[10].FromDate_Day[4]": "<%= form.data['provider_facility'][4]&.dig('treatment_date_range', 'from')&.[](8..9) %>",
-  "F[0].#subform[10].ToDate_Year[4]": "<%= form.data['provider_facility'][4]&.dig('treatment_date_range', 'to')&.[](0..3) %>",
-  "F[0].#subform[10].ToDate_Month[4]": "<%= form.data['provider_facility'][4]&.dig('treatment_date_range', 'to')&.[](5..6) %>",
-  "F[0].#subform[10].ToDate_Day[4]": "<%= form.data['provider_facility'][4]&.dig('treatment_date_range', 'to')&.[](8..9) %>",
-  "F[0].#subform[10].Conditions_You_Are_Being_Treated_For[4]": "<%= form.data['provider_facility'][4]&.dig('conditions_treated') %>",
+  "F[0].#subform[15].Provider_Or_Facility_Name[4]": "<%= form.data['provider_facility'][4]&.dig('provider_facility_name') %>",
+  "F[0].#subform[15].Provider_Facility_Address_ZIPOrPostalCode_FirstFiveNumbers[4]": "<%= form.data['provider_facility'][4]&.dig('provider_facility_address', 'postal_code')&.[](0..4) %>",
+  "F[0].#subform[15].Provider_Facility_Address_ZIPOrPostalCode_LastFourNumbers[4]": "<%= form.data['provider_facility'][4]&.dig('provider_facility_address', 'postal_code')&.[](5..8) %>",
+  "F[0].#subform[15].Provider_Facility_Address_Country[4]": "<%= form.data['provider_facility'][4]&.dig('provider_facility_address', 'country') %>",
+  "F[0].#subform[15].Provider_Facility_Address_StateOrProvince[4]": "<%= form.data['provider_facility'][4]&.dig('provider_facility_address', 'state') %>",
+  "F[0].#subform[15].Provider_Facility_Address_City[4]": "<%= form.data['provider_facility'][4]&.dig('provider_facility_address', 'city') %>",
+  "F[0].#subform[15].MailingAddress_ApartmentOrUnitNumber[4]": "<%= form.data['provider_facility'][4]&.dig('provider_facility_address', 'street2')&.gsub(/\D/, '') %>",
+  "F[0].#subform[15].Provider_Facility_Street_Address_NumberAndStreet[4]": "<%= form.data['provider_facility'][4]&.dig('provider_facility_address', 'street') %>",
+  "F[0].#subform[15].FromDate_Year[4]": "<%= form.data['provider_facility'][4]&.dig('treatment_date_range', 'from')&.[](0..3) %>",
+  "F[0].#subform[15].FromDate_Month[4]": "<%= form.data['provider_facility'][4]&.dig('treatment_date_range', 'from')&.[](5..6) %>",
+  "F[0].#subform[15].FromDate_Day[4]": "<%= form.data['provider_facility'][4]&.dig('treatment_date_range', 'from')&.[](8..9) %>",
+  "F[0].#subform[15].ToDate_Year[4]": "<%= form.data['provider_facility'][4]&.dig('treatment_date_range', 'to')&.[](0..3) %>",
+  "F[0].#subform[15].ToDate_Month[4]": "<%= form.data['provider_facility'][4]&.dig('treatment_date_range', 'to')&.[](5..6) %>",
+  "F[0].#subform[15].ToDate_Day[4]": "<%= form.data['provider_facility'][4]&.dig('treatment_date_range', 'to')&.[](8..9) %>",
+  "F[0].#subform[15].Conditions_You_Are_Being_Treated_For[4]": "<%= form.data['provider_facility'][4]&.dig('conditions_treated') %>",
   "F[0]": "<%= 'F' %>"
 }
diff --git a/modules/simple_forms_api/templates/vba_21_4142.pdf b/modules/simple_forms_api/templates/vba_21_4142.pdf
index 4a5dd51ac4f..f281e3e2be3 100644
Binary files a/modules/simple_forms_api/templates/vba_21_4142.pdf and b/modules/simple_forms_api/templates/vba_21_4142.pdf differ