<input id="streetnumber" size ="7" type="text" value="<!-- TMPL_VAR name="streetnumber" -->" name="streetnumber" />
<input type="text" name="address" value="<!-- TMPL_VAR NAME="address" -->" id="address" />
<input type="text" name="address2" value="<!-- TMPL_VAR NAME="address2" -->" id="address2" /></li>
-<li><label for="city">City, State:</label> <input id="city" type="text" value="<!-- TMPL_VAR name="city" -->" name="city" /></li>
+<li><label for="city">City:</label> <input id="city" type="text" value="<!-- TMPL_VAR name="city" -->" name="city" /></li>
+<li><label for="state">State:</label> <input id="state" type="text" value="<!-- TMPL_VAR name="state" -->" name="state" /></li>
<li><label for="zipcode">Zip Code: </label><input type="text" id="zipcode" value="<!-- TMPL_VAR NAME="zipcode" -->" name="zipcode" /></li>
<li><label for="country">Country: </label><input type="text" id="country" value="<!-- TMPL_VAR NAME="country" -->" name="country" /></li>
<li><label for="phone">Home Phone:</label> <input id="phone" type="text" value="<!-- TMPL_VAR name="phone" -->" name="phone" /></li>
<input id="B_address2" type="text" value="<!-- TMPL_VAR name="B_address2" -->" name="B_address2" />
</li>
-<li><label for="B_city">City, State:</label> <input id="B_city" type="text" value="<!-- TMPL_VAR name="B_city" -->" name="B_city" /></li>
+<li><label for="B_city">City:</label> <input id="B_city" type="text" value="<!-- TMPL_VAR name="B_city" -->" name="B_city" /></li>
+<li><label for="B_state">State:</label> <input id="B_state" type="text" value="<!-- TMPL_VAR name="B_state" -->" name="B_state" /></li>
<li><label for="B_zipcode">Zip Code:</label> <input type="text" id="B_zipcode" value="<!-- TMPL_VAR NAME="B_zipcode" -->" name="B_zipcode" /></li>
<li><label for="B_country">Country:</label> <input type="text" id="B_country" value="<!-- TMPL_VAR NAME="B_country" -->" name="B_country" /></li>
<li><label for="B_phone">Phone:</label> <input type="text" id="B_phone" value="<!-- TMPL_VAR NAME="B_phone" -->" name="B_phone" /></li>
<li><span class="label">Other Name:</span> <!-- TMPL_VAR NAME="othernames" --></li>
<li><span class="label">Address:</span> <!-- TMPL_VAR NAME="streetnumber" --> <!-- TMPL_VAR NAME="address" --></li>
<li><span class="label"> </span><!-- TMPL_VAR NAME="address2" --></li>
-<li><span class="label">City, State:</span> <!-- TMPL_VAR name="city" --></li>
+<li><span class="label">City:</span> <!-- TMPL_VAR name="city" --></li>
+<li><span class="label">State:</span> <!-- TMPL_VAR name="state" --></li>
<li><span class="label">Zip Code:</span> <!-- TMPL_VAR NAME="zipcode" --></li>
<li><span class="label">Country:</span> <!-- TMPL_VAR NAME="country" --></li>
<li><span class="label">Home Phone:</span> <!-- TMPL_VAR name="phone" --></li>
<ol>
<li><span class="label">Alternate Address:</span> <!--TMPL_VAR NAME="B_streetnumber"--> <!-- TMPL_VAR name="B_address" --> </li>
<li><span class="label"> </span><!-- TMPL_VAR NAME="B_address2" --></li>
-<li><span class="label">City, State:</span> <!-- TMPL_VAR name="B_city" --></li>
+<li><span class="label">City:</span> <!-- TMPL_VAR name="B_city" --></li>
+<li><span class="label">State:</span> <!-- TMPL_VAR name="B_state" --></li>
<li><span class="label">Zip Code:</span> <!-- TMPL_VAR NAME="B_zipcode" --></li>
<li><span class="label">Country:</span> <!-- TMPL_VAR NAME="B_country" --></li>
<li><span class="label">Phone:</span> <!-- TMPL_VAR NAME="B_phone" --></li>