pwchomerepairs.givecloud.co
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2606:4700:10::6816:2680
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Submitted URL: https://support.pwchomerepairs.org/
Effective URL: https://pwchomerepairs.givecloud.co/
Submission: On August 03 via automatic, source certstream-suspicious — Scanned from DE
Effective URL: https://pwchomerepairs.givecloud.co/
Submission: On August 03 via automatic, source certstream-suspicious — Scanned from DE
Form analysis 2 forms found in the DOM
POST https://pwchomerepairs.givecloud.co/account/login
<form action="https://pwchomerepairs.givecloud.co/account/login" method="post">
<input type="hidden" name="_token" value="ujCioyghccrg0UIMoe3lsIxOhvPKCZGszOu0l4mE">
<div class="form-group labelify">
<label><i class="fa fa-envelope-o"></i> Email</label>
<input type="email" name="email" autocomplete="username" class="form-control">
</div>
<div class="form-group labelify">
<label><i class="fa fa-lock"></i> Password</label>
<input type="password" name="password" autocomplete="current-password" class="form-control">
</div>
<div class="custom-control custom-checkbox mt-0 mb-3">
<input type="checkbox" class="custom-control-input" id="rememberMeInput" name="remember_me" value="1">
<label class="custom-control-label" for="rememberMeInput">Remember me</label>
</div>
<div class="text-center mb-2">
<button type="submit" class="btn btn-block btn-pill btn-primary"><i class="fa fa-log-in"></i> Sign-In</button>
<div class="text-center mt-2 text-sm">
<a href="/account/reset-password">I Forgot My Password</a>
</div>
</div>
<hr>
<div class="text-sm text-center">
<a href="/account/register" class="btn btn-block btn-pill btn-secondary"><i class="fa fa-log-in"></i> Create an Account</a>
</div>
</form>POST
<form id="product-payment-app" data-vv-scope="pay" method="post" novalidate="novalidate" data-requires-ach="false" class="">
<div class="container no-gutters">
<div id="amount_section" class="row">
<div class="col-12 text-center">
<div class="my-5 wow fadeInUp" style="visibility: visible; animation-name: fadeInUp;">
<div class="product-options">
<div class="form-group mb-3 ">
<div data-toggle="buttons" class="btn-group-toggle btn-group-checked d-inline-block"><label for="variant_id_blank" class="d-none">None</label> <input id="variant_id_blank" type="radio" name="variant_id" value="" required="required"
class="d-none"> <label for="variant_id_2" class="btn btn-outline-secondary mb-1 mr-1 active"><input type="radio" id="variant_id_2" name="variant_id" value="2" data-price="0" data-on-sale="" data-sale-price="0" data-donation="1"
data-billing-period="monthly" data-price-presets="100,50,25,15,5,other" data-price-preset-other="Other" data-minimum-price="5" data-other-amount="" data-recurring-first-payment="1" data-redirect="" data-available="1"
data-out-of-stock-message="" data-shipping-expectation="" data-preserve-amount="1" checked="checked"> Monthly</label> <label for="variant_id_1" class="btn btn-outline-secondary mb-1 mr-1 "><input type="radio" id="variant_id_1"
name="variant_id" value="1" data-price="0" data-on-sale="" data-sale-price="0" data-donation="1" data-billing-period="onetime" data-price-presets="500,250,100,50,25,other" data-price-preset-other="Other" data-minimum-price="5"
data-other-amount="" data-recurring-first-payment="1" data-redirect="" data-available="1" data-out-of-stock-message="" data-shipping-expectation="" data-preserve-amount="1"> One-Time</label></div>
</div> <input type="hidden" name="amt" value="100">
<div data-hide-pricing="false" class="pricing-container d-flex flex-wrap justify-content-center align-items-center">
<div class="btn-group-toggle form-primary btn-group-checked d-inline-block price-presets" data-toggle="buttons" role="group" aria-labelledby="presets_heading"><label class="sr-only" id="presets_heading">Choose an Amount</label><label
class="btn btn-lg btn-outline-primary mb-1 mr-1 active"><input type="radio" name="preset_amount" value="100"> $100</label><label class="btn btn-lg btn-outline-primary mb-1 mr-1"><input type="radio" name="preset_amount" value="50">
$50</label><label class="btn btn-lg btn-outline-primary mb-1 mr-1"><input type="radio" name="preset_amount" value="25"> $25</label><label class="btn btn-lg btn-outline-primary mb-1 mr-1"><input type="radio" name="preset_amount"
value="15"> $15</label><label class="btn btn-lg btn-outline-primary mb-1 mr-1"><input type="radio" name="preset_amount" value="5"> $5</label>
<div class="form-group d-inline-block mb-1 mr-1 labelify bs-validate"><label for="p-variant-id-2">Other</label><input id="p-variant-id-2" style="width:120px;" type="number" step="0.01"
class="font-weight-bold form-control form-control-outline" name="other_amount" value=""></div>
</div>
<div class="minimum-price-notice w-100 mb-1 text-primary text-muted" data-minimum-price="5.00">There is a minimum donation of $5.00</div>
</div> <!----> <input type="hidden" name="recurring_day" value="3"> <input type="hidden" name="recurring_day_of_week" value="4">
</div>
</div>
</div>
</div>
<div class="row" style="display: none;">
<div class="col-12 col-md-6 offset-md-3">
<div class="card mb-4">
<div class="card-body">
<div class="form-row">
<div class="form-group col labelify has-errors"><label for="inputPledgeFirstName">First Name</label> <input id="inputPledgeFirstName" type="text" name="billing_first_name" data-vv-scope="pledge" x-autocompletetype="given-name"
autocompletetype="given-name" autocorrect="off" spellcheck="true" autocapitalize="off" class="form-control pristine untouched invalid" aria-required="true" aria-invalid="true"></div>
<div class="form-group col-8 labelify has-errors"><label for="inputPledgeLastName">Last Name</label> <input id="inputPledgeLastName" type="text" name="billing_last_name" data-vv-scope="pledge" x-autocompletetype="surname"
autocompletetype="family-name" autocorrect="off" spellcheck="true" autocapitalize="off" class="form-control pristine untouched invalid" aria-required="true" aria-invalid="true"></div>
</div>
<div class="form-group labelify mb-0 has-errors"><label for="inputPledgeEmail"><i class="fa fa-envelope-o"></i> Email</label> <input id="inputPledgeEmail" type="text" name="billing_email" data-vv-scope="pledge" x-autocompletetype="email"
autocompletetype="email" autocorrect="off" spellcheck="true" autocapitalize="off" class="form-control pristine untouched invalid" aria-required="true" aria-invalid="true"></div>
<div class="form-group labelify mt-3 mb-0"><label for="inputPledgePhone"><i class="fa fa-phone"></i> Phone</label> <input id="inputPledgePhone" type="text" name="billing_phone" x-autocompletetype="phone-full" autocompletetype="tel"
autocorrect="off" spellcheck="true" autocapitalize="off" class="form-control"></div>
</div>
</div> <!---->
<div class="mb-4"><button type="submit" id="btn-pledge" class="btn btn-block btn-xl btn-pill btn-success mb-3"><i class="fa fa-lock"></i> Pledge $100.00 </button>
<div class="text-center">
<div class="gc-lock"> Encrypted & Secure. Give with Confidence.<br><span
class="text-muted"><a href="https://givecloud.co/?utm_source=pwchomerepairs&utm_medium=gc-secure" target="_blank" rel="noopener">Powered by Givecloud.</a></span></div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-12 col-md-6 col-lg-7"><input type="hidden" name="product_id" value="1"> <input type="hidden" name="recurring_frequency" value="monthly">
<div class="card mb-4 wow fadeInUp" style="visibility: visible; animation-name: fadeInUp;">
<div class="card-body">
<h3 class="text-left mb-4">Dedicate</h3>
<div class="row ">
<div class="col-12">
<div class="form-group"><label for="">Do you want to dedicate this donation in memory or in honor of someone?</label>
<div data-toggle="buttons">
<div class="btn-group-toggle btn-group-checked mb-3"><label class="btn btn-outline-secondary "><input type="radio" name="is_tribute" value="1"> Yes</label> <label class="btn btn-outline-secondary active"><input type="radio"
name="is_tribute" checked="checked" value="0"> No</label></div>
</div>
</div>
</div>
</div>
<div class="tribute-wrap collapse"><label>Dedicate This Donation</label>
<div class="row gutter-sm">
<div class="col-sm-6 col-md-5 ">
<div class="form-group labelify"><label for="tribute_type_id">Dedication Type</label> <select id="tribute_type_id" name="tribute_type_id" class="form-control">
<option value="1">In memory of</option>
<option value="2">In honor of</option>
</select></div>
</div>
<div class="col-sm-6 col-md-7">
<div class="form-group labelify"><label for="tribute_name">Tribute Name<span class="asterisk-required">*</span></label> <input id="tribute_name" type="text" name="tribute_name" class="form-control">
<div class="invalid-feedback">Who are you dedicating this to?</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="form-group">
<div data-toggle="buttons">
<div class="btn-group-toggle btn-group-checked mb-3"><label class="btn btn-outline-secondary mb-1 "><input type="radio" name="tribute_notify" value="letter" autocomplete="off"> Send a Letter </label> <label
class="btn btn-outline-secondary mb-1 active"><input type="radio" name="tribute_notify" value="" autocomplete="off" checked="checked"> None </label></div>
</div>
</div>
</div>
</div>
<div class="tribute-recipient-wrap collapse "><label>Send notification of tribute to<span class="asterisk-required">*</span></label>
<div class="row gutter-sm">
<div class="tribute-mail tribute-email col-sm-6">
<div class="form-group labelify"><label for="tribute_notify_name">Full Name<span class="asterisk-required">*</span></label> <input id="tribute_notify_name" type="text" name="tribute_notify_name" data-bv-notempty=""
data-bv-notempty-message="Name is missing." class="form-control">
<div class="invalid-feedback">Who is receiving the dedication notice?</div>
</div>
</div>
<div class="tribute-email col-sm-6">
<div class="form-group labelify"><label for="tribute_notify_email"><i class="fa fa-envelope-o"></i> Email<span class="asterisk-required">*</span></label> <input id="tribute_notify_email" type="email" name="tribute_notify_email"
data-bv-notempty="" data-bv-notempty-message="Email is missing." class="form-control">
<div class="invalid-feedback">What is their email address?</div>
</div>
</div>
</div>
<div class="tribute-mail">
<div class="row gutter-sm">
<div class="col-12">
<div class="form-group labelify">
<div><label for="ptmf-alu-1">Street Address</label><input id="ptmf-alu-1" name="tribute_notify_address" type="text" placeholder="Street and number, P.O. box, c/o." x-autocompletetype="address-line1"
autocompletetype="address-line1" autocorrect="off" spellcheck="true" autocapitalize="off" class="form-control"></div>
<div class="invalid-feedback">Which address are we sending the notice to?</div>
</div>
</div>
<div class="col-5">
<div class="form-group labelify"><label for="tribute_notify_city">City</label><input type="text" id="tribute_notify_city" name="tribute_notify_city" x-autocompletetype="city" autocompletetype="city" autocorrect="off"
spellcheck="true" autocapitalize="off" class="form-control">
<div class="invalid-feedback">Which city?</div>
</div>
</div>
<div class="col-3">
<div class="form-group labelify"><label for="tribute_notify_state">Province</label><input id="tribute_notify_state" type="text" name="tribute_notify_state" class="form-control"></div>
</div>
<div class="col-4">
<div class="form-group labelify"><label for="tribute_notify_zip">Postal</label><input type="text" id="tribute_notify_zip" name="tribute_notify_zip" x-autocompletetype="postal-code" autocompletetype="postal-code"
autocorrect="off" spellcheck="true" autocapitalize="off" class="form-control">
<div class="invalid-feedback">What is the ZIP?</div>
</div>
</div>
<div class="col-8">
<div class="form-group labelify"><label for="tribute_notify_country">Country</label><select id="tribute_notify_country" name="tribute_notify_country" class="form-control">
<option value="CA">Canada</option>
<option value="US">United States</option>
<option value=""></option>
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua & Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia</option>
<option value="BA">Bosnia & Herzegovina</option>
<option value="BW">Botswana</option>
<option value="BV">Bouvet Island</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="VG">British Virgin Islands</option>
<option value="BN">Brunei</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CV">Cape Verde</option>
<option value="BQ">Caribbean Netherlands</option>
<option value="KY">Cayman Islands</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CW">Curaçao</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czechia</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="SZ">Eswatini</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="GG">Guernsey</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard & McDonald Islands</option>
<option value="HN">Honduras</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IE">Ireland</option>
<option value="IM">Isle of Man</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JE">Jersey</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Laos</option>
<option value="LV">Latvia</option>
<option value="LS">Lesotho</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macao SAR China</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="MT">Malta</option>
<option value="MH">Marshall Islands</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia</option>
<option value="MD">Moldova</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="ME">Montenegro</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="MK">North Macedonia</option>
<option value="MP">Northern Mariana Islands</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PS">Palestinian Territories</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn Islands</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RO">Romania</option>
<option value="RW">Rwanda</option>
<option value="RE">Réunion</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SX">Sint Maarten</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia & South Sandwich Islands</option>
<option value="KR">South Korea</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="BL">St. Barthélemy</option>
<option value="SH">St. Helena</option>
<option value="KN">St. Kitts & Nevis</option>
<option value="LC">St. Lucia</option>
<option value="MF">St. Martin</option>
<option value="PM">St. Pierre & Miquelon</option>
<option value="VC">St. Vincent & Grenadines</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard & Jan Mayen</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="ST">São Tomé & Príncipe</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="TL">Timor-Leste</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad & Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks & Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UM">U.S. Outlying Islands</option>
<option value="VI">U.S. Virgin Islands</option>
<option value="UG">Uganda</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican City</option>
<option value="VN">Vietnam</option>
<option value="WF">Wallis & Futuna</option>
<option value="EH">Western Sahara</option>
<option value="ZM">Zambia</option>
<option value="AX">Åland Islands</option>
</select>
<div class="invalid-feedback">Which country?</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-12">
<div class="form-group tribute-mail tribute-email"><label for="tribute_message">Personal Message</label> <textarea id="tribute_message" rows="3" name="tribute_message" class="form-control"></textarea> <small
class="text-muted">Optional. Write a personal note to the recipient.</small></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="card mb-4 wow fadeInUp " style="visibility: hidden; animation-name: none;">
<div class="card-body">
<div id="p1-f9-container" class="form-group "><label for="p1-f9">Anonymous donation? Yes/No<span class="asterisk-required">*</span></label> <select name="form_fields[9]" required="required" class="form-control">
<option value="N"> No </option>
<option value="Y"> Yes </option>
</select>
<div class="invalid-feedback">This field is required.</div>
</div>
<div id="p1-f10-container" class="form-group "><label for="p1-f10">Matching Company</label> <input id="p1-f10" type="text" name="form_fields[10]" value="" placeholder="" class="form-control ">
<div class="invalid-feedback">This field is required.</div>
</div>
</div>
</div>
<div class="card mb-4 wow fadeInUp" style="visibility: hidden; animation-name: none;">
<div class="card-body">
<h4 class="text-left d-block mb-3">Billing</h4>
<div class="form-group">
<div class="btn-group-toggle mb-3"><label class="btn btn-outline-dark active"><input type="radio" name="account_type_id" value="1"> Individual </label><label class="btn btn-outline-dark"><input type="radio" name="account_type_id"
value="2"> Organization </label></div>
</div>
<div class="form-row">
<div class="form-group col-2 labelify"><label for="inputBillingTitle">Title</label> <select id="inputBillingTitle" name="billing_title" x-autocompletetype="honorific-prefix" autocompletetype="honorific-prefix" class="form-control">
<option value=""></option>
<option value="Ms.">Ms.</option>
<option value="Mr.">Mr.</option>
<option value="Mrs.">Mrs.</option>
<option value="Mr. and Mrs.">Mr. and Mrs.</option>
<option value="Mx.">Mx.</option>
<option value="Dr.">Dr.</option>
</select></div>
<div class="form-group col labelify has-errors"><label for="inputBillingFirstName">First Name</label> <input id="inputBillingFirstName" type="text" name="billing_first_name" x-autocompletetype="given-name" autocompletetype="given-name"
autocorrect="off" spellcheck="true" autocapitalize="off" class="form-control pristine untouched invalid" aria-required="true" aria-invalid="true"></div>
<div class="form-group col-6 labelify has-errors"><label for="inputBillingLastName">Last Name</label> <input id="inputBillingLastName" type="text" name="billing_last_name" x-autocompletetype="surname" autocompletetype="family-name"
autocorrect="off" spellcheck="true" autocapitalize="off" class="form-control pristine untouched invalid" aria-required="true" aria-invalid="true"></div>
</div> <!---->
<div class="form-group labelify has-errors"><label for="inputBillingEmail"><i class="fa fa-envelope-o"></i> Email</label> <input id="inputBillingEmail" type="text" name="billing_email" x-autocompletetype="email" autocompletetype="email"
autocorrect="off" spellcheck="true" autocapitalize="off" class="form-control pristine untouched invalid" aria-required="true" aria-invalid="true"></div>
<div class="form-group labelify"><label for="inputBillingPhone"><i class="fa fa-phone"></i> Phone</label> <input id="inputBillingPhone" type="text" name="billing_phone" x-autocompletetype="phone-full" autocompletetype="tel"
autocorrect="off" spellcheck="true" autocapitalize="off" class="form-control"></div>
<div>
<div class="create-account-wrapper">
<h5 class="mb-3"> Create Account </h5>
<p>Enter a password and we'll save your info for next time.</p>
<div class="form-group labelify"><label for="inputPassword"><i class="fa fa-lock"></i> Password</label> <input id="inputPassword" type="password" name="password" autocomplete="new-password"
class="form-control pristine untouched valid" aria-required="false" aria-invalid="false"></div>
</div>
<div class="mt-4">
<h5 class="mb-3"> How'd you hear about us? </h5>
<div class="form-group">
<div class="btn-group-toggle mb-3"><label class="btn btn-outline-dark mr-1 mb-1"><input type="radio" name="referral_source" value="Facebook"> Facebook </label><label class="btn btn-outline-dark mr-1 mb-1"><input type="radio"
name="referral_source" value="Instagram"> Instagram </label><label class="btn btn-outline-dark mr-1 mb-1"><input type="radio" name="referral_source" value="Website"> Website </label><label
class="btn btn-outline-dark mr-1 mb-1"><input type="radio" name="referral_source" value="Friend/Family"> Friend/Family </label><label class="btn btn-outline-dark mr-1 mb-1"><input type="radio" name="referral_source"
value="Event"> Event </label><label class="btn btn-outline-dark mr-1 mb-1"><input type="radio" name="referral_source" value="other"> Other: </label></div>
</div> <!---->
</div>
</div>
</div>
</div>
<div class="d-none d-sm-none d-md-block">
<div class="social-actions card mb-4 ">
<div class="card-body">
<div class="card-title-sm mb-4"><i class="fa fa-users"></i> Share This</div>
<div class="row gutter-sm">
<div class="col">
<a href="https://www.facebook.com/sharer/sharer.php?display=popup&redirect_uri=http%3A%2F%2Fwww.facebook.com&u=https%3A%2F%2Fpwchomerepairs.givecloud.co%2Fgive&t=Help+Save+Homes+and+Restore+Hope" target="_blank" rel="noopener" class="btn btn-sm btn-pill btn-outline-primary btn-block"><i class="fa fa-facebook fa-fw"></i></a>
</div>
<div class="col">
<a href="https://twitter.com/intent/tweet?text=Help+Save+Homes+and+Restore+Hope&url=https%3A%2F%2Fpwchomerepairs.givecloud.co%2Fgive" target="_blank" rel="noopener" class="btn btn-sm btn-pill btn-outline-primary btn-block"><i class="fa fa-twitter fa-fw"></i></a>
</div>
<div class="col">
<a href="mailto:?subject=Help%20Save%20Homes%20and%20Restore%20Hope&body=Donate%20today%20or%20sign%20up%20for%20monthly%20giving%20to%20make%20an%20impact%20all%20year%20long%0A%0ARead%20More%3A%20https%3A%2F%2Fpwchomerepairs.givecloud.co%2Fgive" class="btn btn-sm btn-pill btn-outline-primary btn-block"><i class="fa fa-envelope fa-fw"></i></a>
</div>
<div class="col">
<a href="https://www.linkedin.com/shareArticle?mini=1&url=https%3A%2F%2Fpwchomerepairs.givecloud.co%2Fgive&title=Help+Save+Homes+and+Restore+Hope&summary=Donate+today+or+sign+up+for+monthly+giving+to+make+an+impact+all+year+long" target="_blank" rel="noopener" class="btn btn-sm btn-pill btn-outline-primary btn-block"><i class="fa fa-linkedin fa-fw"></i></a>
</div>
<div class="col">
<a href="https://www.pinterest.com/pin/create/button/?url=https%3A%2F%2Fpwchomerepairs.givecloud.co%2Fgive&description=Help+Save+Homes+and+Restore+Hope&media=https%3A%2F%2Fcdn.givecloud.co%2Fs%2Ffiles%2F2%2F0000%2F3412%2Ffiles%2Fimg-1476_300x_cropped_top.jpg" target="_blank" rel="noopener" class="btn btn-sm btn-pill btn-outline-primary btn-block"><i class="fa fa-pinterest fa-fw"></i></a>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col-12 col-md-6 col-lg-5">
<div class="card mb-4 wow fadeInUp" style="visibility: visible; animation-name: fadeInUp;">
<div class="card-body">
<h4 class="text-left d-block mb-3">Payment</h4>
<nav class="nav nav nav-pills nav-fill mb-3"><button type="button" class="btn btn-link nav-item nav-link active"><i class="fa fa-credit-card"></i> Credit / Debit </button> <button type="button"
class="btn btn-link nav-item nav-link"><i class="fa fa-bank"></i> Bank </button> <!----> <!----></nav>
<div class="credit-card-fields">
<div class="form-group labelify payment-number-input has-errors"><label for="inputPaymentNumber">Credit Card Number</label>
<div data-private=""><input type="tel" id="inputPaymentNumber" maxlength="19" placeholder="0000 0000 0000 0000" name="number" x-autocompletetype="cc-number" autocompletetype="cc-number" autocorrect="off" spellcheck="true"
autocapitalize="off" class="form-control monospace" aria-required="true" aria-invalid="true"></div> <!----> <!---->
</div>
<div class="form-row">
<div class="form-group col-6 labelify has-errors"><label for="inputPaymentExpiry">MM / YY</label>
<div data-private=""><input type="tel" id="inputPaymentExpiry" maxlength="7" placeholder="MM / YY" name="exp" x-autocompletetype="cc-exp" autocompletetype="cc-exp" autocorrect="off" spellcheck="true" autocapitalize="off"
class="form-control monospace" aria-required="true" aria-invalid="true"></div>
</div>
<div class="form-group col-6 labelify has-errors"><label for="inputPaymentCVV">CVV</label>
<div data-private=""><input type="tel" id="inputPaymentCVV" maxlength="4" placeholder="000" name="cvv" x-autocompletetype="cc-csc" autocompletetype="cc-csc" autocorrect="off" spellcheck="true" autocapitalize="off"
class="form-control monospace" aria-required="true" aria-invalid="true"></div>
</div>
</div> <!---->
<div class="supported-cardtypes mt-1 text-center"><strong>We support:</strong> <img alt="" src="https://cdn.givecloud.co/npm/payment-icons@1.1.0/min/flat/amex.svg"> <!----> <img alt=""
src="https://cdn.givecloud.co/npm/payment-icons@1.1.0/min/flat/discover.svg"> <!----> <!----> <img alt="" src="https://cdn.givecloud.co/npm/payment-icons@1.1.0/min/flat/mastercard.svg"> <!----> <img alt=""
src="https://cdn.givecloud.co/npm/payment-icons@1.1.0/min/flat/visa.svg"></div>
</div>
</div>
</div>
<div class="card mb-4 wow fadeInUp" style="visibility: hidden; animation-name: none;">
<div class="card-body">
<div>
<h4 class="text-left d-block mb-3">Address</h4>
<div class="form-group labelify">
<div><label for="inputBillingAddress1">Address</label><input id="inputBillingAddress1" name="billing_address1" type="text" placeholder="Street and number, P.O. box, c/o." required="required" x-autocompletetype="address-line1"
autocompletetype="address-line1" autocorrect="off" spellcheck="true" autocapitalize="off" class="form-control"></div>
</div>
<div class="form-group labelify"><label for="inputBillingAddress2">Address 2</label> <input id="inputBillingAddress2" type="text" placeholder="Apartment, suite, unit, building, floor, etc." name="billing_address2"
x-autocompletetype="address-line2" autocompletetype="address-line2" autocorrect="off" spellcheck="true" autocapitalize="off" class="form-control"></div>
<div class="form-row">
<div class="form-group col-8 labelify has-errors"><label for="inputBillingCity">City</label> <input id="inputBillingCity" type="text" name="billing_city" x-autocompletetype="city" autocompletetype="city" autocorrect="off"
spellcheck="true" autocapitalize="off" class="form-control pristine untouched invalid" aria-required="true" aria-invalid="true"></div>
<div class="form-group col-4 labelify has-errors"><label for="inputBillingZip">ZIP</label> <input id="inputBillingZip" type="text" name="billing_zip" x-autocompletetype="postal-code" autocompletetype="postal-code" autocorrect="off"
spellcheck="true" autocapitalize="off" class="form-control pristine untouched invalid" aria-required="true" aria-invalid="true"></div>
</div>
<div class="form-row">
<div class="form-group col-7 labelify"><label for="inputBillingCountry">Country</label> <select id="inputBillingCountry" name="billing_country_code" class="form-control pristine untouched valid" aria-required="true"
aria-invalid="false">
<option></option>
<option value="CA">Canada</option>
<option value="US">United States</option>
<option value="">--------</option>
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua & Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia</option>
<option value="BA">Bosnia & Herzegovina</option>
<option value="BW">Botswana</option>
<option value="BV">Bouvet Island</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="VG">British Virgin Islands</option>
<option value="BN">Brunei</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CV">Cape Verde</option>
<option value="BQ">Caribbean Netherlands</option>
<option value="KY">Cayman Islands</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CW">Curaçao</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czechia</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="SZ">Eswatini</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="GG">Guernsey</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard & McDonald Islands</option>
<option value="HN">Honduras</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IE">Ireland</option>
<option value="IM">Isle of Man</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JE">Jersey</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Laos</option>
<option value="LV">Latvia</option>
<option value="LS">Lesotho</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macao SAR China</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="MT">Malta</option>
<option value="MH">Marshall Islands</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia</option>
<option value="MD">Moldova</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="ME">Montenegro</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="MK">North Macedonia</option>
<option value="MP">Northern Mariana Islands</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PS">Palestinian Territories</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn Islands</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RO">Romania</option>
<option value="RW">Rwanda</option>
<option value="RE">Réunion</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SX">Sint Maarten</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia & South Sandwich Islands</option>
<option value="KR">South Korea</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="BL">St. Barthélemy</option>
<option value="SH">St. Helena</option>
<option value="KN">St. Kitts & Nevis</option>
<option value="LC">St. Lucia</option>
<option value="MF">St. Martin</option>
<option value="PM">St. Pierre & Miquelon</option>
<option value="VC">St. Vincent & Grenadines</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard & Jan Mayen</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="ST">São Tomé & Príncipe</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="TL">Timor-Leste</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad & Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks & Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UM">U.S. Outlying Islands</option>
<option value="VI">U.S. Virgin Islands</option>
<option value="UG">Uganda</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican City</option>
<option value="VN">Vietnam</option>
<option value="WF">Wallis & Futuna</option>
<option value="EH">Western Sahara</option>
<option value="ZM">Zambia</option>
<option value="AX">Åland Islands</option>
</select></div>
<div class="form-group col-5 labelify has-errors"><label for="inputBillingProvince">State</label> <select id="inputBillingProvince" name="billing_province_code" class="form-control pristine untouched invalid" aria-required="true"
aria-invalid="true">
<option></option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AS">American Samoa</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="AE">Armed Forces of Europe</option>
<option value="AA">Armed Forces of the Americas</option>
<option value="AP">Armed Forces of the Pacific</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="GU">Guam</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="MP">Northern Mariana Islands</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VI">Virgin Islands</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select></div>
</div>
</div>
</div>
</div>
<div class="card mb-4 wow fadeInUp" style="visibility: hidden; animation-name: none;">
<div class="card-body">
<div>
<div class="d-flex justify-content-between mb-3">
<h4 class="text-left mb-0"> + Cover Costs & Fees </h4> <a href="#" data-toggle="modal" data-target="#dcc-information-modal" style="color: inherit;"><i class="fa fa-info-circle small"></i></a>
</div>
<p>Help eliminate processing fees and the cost of managing your payment so we can maximize your impact.</p>
<div class="form-group"><label for="inputCoverCostsType" class="sr-only">Cover Costs & Fees</label> <select id="inputCoverCostsType" name="cover_costs_type" class="form-control">
<option value="most_costs">$14.20 - Most Costs</option>
<option value="more_costs">$10.52 - More Costs</option>
<option value="minimum_costs">$7.79 - Minimum Costs</option>
<option value="">No Thank You</option>
</select></div>
</div>
</div>
</div> <!---->
<div class="mb-4">
<div class=" d-none d-md-block"><button type="submit" id="btn-pay" class="btn btn-block btn-xl btn-pill btn-success mb-3"><i class="fa fa-lock"></i> Complete my donation ($110.52) </button>
<div class="text-center">
<div class="gc-lock"> Encrypted & Secure. Give with Confidence.<br><span
class="text-muted"><a href="https://givecloud.co/?utm_source=pwchomerepairs&utm_medium=gc-secure" target="_blank" rel="noopener">Powered by Givecloud.</a></span></div>
</div>
</div>
<div data-sticky-after="#amount_section" class="sticky-div hide-important fixed-bottom shadow-sm p-3 d-flex d-sm-flex d-md-none text-center bg-white align-items-center justify-content-between">
<div class="text-left">
<div class="gc-lock"> Encrypted & Secure. Give with Confidence.<br><span
class="text-muted"><a href="https://givecloud.co/?utm_source=pwchomerepairs&utm_medium=gc-secure" target="_blank" rel="noopener">Powered by Givecloud.</a></span></div>
</div>
<div><button type="submit" class="btn btn-block btn-lg btn-pill btn-success px-3"><i class="fa fa-lock"></i> Complete my donation ($110.52) </button></div>
</div>
</div>
</div>
</div>
<div class="row d-md-none">
<div class="col-12 col-md-6 col-lg-7">
<div class="social-actions card mb-4 ">
<div class="card-body">
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