Trusted Form

Lead Verification Details

Securely captured and verified lead information

This lead has been verified and consent recorded.

Contact Information

First Name

Esther

Last Name

Samaroo

ZIP Code

11416

State

NY

Date of Birth

1945-10-01

Verification Log

TokenLT-MVFRHRDN-S32QRA
Submitted10/19/2026, 9:23:53 PM
IP Address58.65.217.146
Time on Form1039s
Consent✓ Recorded