Trusted Form

Lead Verification Details

Securely captured and verified lead information

This lead has been verified and consent recorded.

Contact Information

First Name

david

Last Name

moore

ZIP Code

13760

State

NY

Date of Birth

1945-11-11

Verification Log

TokenLT-MVGRF6B3-L5OSDC
Submitted10/20/2026, 2:09:38 PM
IP Address58.65.217.146
Time on Form1142s
Consent✓ Recorded