{"status":"success","response":"<div id=\"custom_forms\">\n\n<div class=\"report_row\" id=\"custom_field_row_3\"><h4>Region <\/h4><input type=\"text\" name=\"custom_field[3]\" value=\"\" id=\"custom_field_3\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_4\"><h4>Municipality <\/h4><input type=\"text\" name=\"custom_field[4]\" value=\"\" id=\"custom_field_4\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_16\"><h4>Province<span class='required'> *<\/span> <\/h4><select name=\"custom_field[16]\" id=\"custom_field_16\">\n<option value=\"COMPOSTELA VALLEY\">COMPOSTELA VALLEY<\/option>\n<option value=\"DAVAO DEL NORTE\">DAVAO DEL NORTE<\/option>\n<option value=\"DAVAO DEL SUR\">DAVAO DEL SUR<\/option>\n<option value=\"DAVAO ORIENTAL\">DAVAO ORIENTAL<\/option>\n<option value=\"AGUSAN DEL NORTE\">AGUSAN DEL NORTE<\/option>\n<option value=\"AGUSAN DEL SUR\">AGUSAN DEL SUR<\/option>\n<option value=\"DINAGAT ISLANDS\">DINAGAT ISLANDS<\/option>\n<option value=\"SURIGAO DEL NORTE\">SURIGAO DEL NORTE<\/option>\n<option value=\"SURIGAO DEL SUR\">SURIGAO DEL SUR<\/option>\n<\/select><\/div><div class=\"report_row\" id=\"custom_field_row_15\"><h4>Barangay <\/h4><input type=\"text\" name=\"custom_field[15]\" value=\"\" id=\"custom_field_15\" class=\"text custom_text\" \/><\/div><\/div>"}