Trusted Form

Lead Verification Details

Securely captured and verified lead information

This lead has been verified and consent recorded.

Contact Information

First Name

laverne

Last Name

seegert

ZIP Code

43570

State

OH

Date of Birth

1954-11-11

Verification Log

TokenFE-MVSLWX5S-M8466H
Submitted10/28/2026, 9:08:43 PM
IP Address58.65.217.146
Time on Form236s
Consent✓ Recorded