Trusted Form

Lead Verification Details

Securely captured and verified lead information

This lead has been verified and consent recorded.

Contact Information

First Name

Lewis

Last Name

Lafountain

ZIP Code

12921

State

NY

Date of Birth

1942-12-04

Verification Log

TokenLT-MVFR70CC-U46IOY
Submitted10/19/2026, 9:15:31 PM
IP Address58.65.217.146
Time on Form387s
Consent✓ Recorded