<!-- BEGIN NAME -->
{NAME_LABEL}:  {NAME}<br />
<!-- END NAME -->
<!-- BEGIN USE_MORTCALC -->
{USE_MORTCALC}<br />
<!-- END USE_MORTCALC -->
<!-- BEGIN USE_PRICE -->
{USE_PRICE}<br />
<!-- END USE_PRICE -->
<!-- BEGIN SUBMIT -->
<br />{SUBMIT_BUTTON}
<!-- END SUBMIT -->