veteransupport.us
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67.225.146.145
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URL:
https://veteransupport.us/
Submission: On August 08 via automatic, source certstream-suspicious — Scanned from US
Submission: On August 08 via automatic, source certstream-suspicious — Scanned from US
Form analysis
1 forms found in the DOMPOST /contact.php
<form action="/contact.php" method="post" id="myForm" onsubmit="return validate(this)">
<table>
<tbody>
<tr>
<td><label for="firstName">First Name<br>
<input id="firstName" name="firstName" type="text" size="21">
</label></td>
<td><label for="lastName">Last Name<br>
<input id="lastName" name="lastName" type="text" size="21">
</label></td>
</tr>
<tr>
<td><label for="address">Mailing Address<br>
<input id="address" name="address" type="text" size="21">
</label></td>
<td><label for="city">City<br>
<input id="city" name="city" type="text" size="21">
</label></td>
</tr>
<tr>
<td><label for="state">State<br>
<select id="state" name="state" size="1">
<option value="None Selected" selected="selected">Please Select:</option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AR">AR</option>
<option value="AZ">AZ</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
</select>
</label></td>
<td><label for="zip">Zip-code<br>
<input id="zip" name="zip" type="text" size="5" maxlength="5">
</label></td>
</tr>
<tr>
<td><label for="phone">Telephone<br>
<input id="phone" name="phone" type="text" size="21">
</label></td>
<td><label for="email">E-Mail Address<br>
<input id="email" name="email" type="text" size="21">
</label></td>
</tr>
<tr>
<td colspan="2"><label>
<input name="diagnosed" type="checkbox" id="diagnosed" value="with mesothelioma" checked=""> Diagnosed with Mesothelioma</label><br><br></td>
</tr>
<tr>
<td colspan="2"><label><strong>In addition, please send me the following:</strong></label></td>
</tr>
<tr>
<td colspan="2"><input type="checkbox" name="packet1" value="Federal Benefits for Dependents and Survivors 2010">
<label for="packet1">Federal Benefits for Dependents & Survivors</label>
</td>
</tr>
<tr>
<td colspan="2"><input type="checkbox" name="packet2" value="Understanding
and Enrolling in the VHA">
<label for="packet2">Understanding and Enrolling in the VHA</label>
</td>
</tr>
<tr>
<td colspan="2"><input type="checkbox" name="packet3" value="Disability Claim Forms">
<label for="packet3">Disability Claim Forms</label>
</td>
</tr>
<tr>
<td colspan="2"><label for="comment">Comments / Questions<br>
<textarea id="comment" name="comment" cols="" rows=""></textarea>
</label></td>
</tr>
<tr>
<td colspan="2"><input id="submit" type="submit" name="submit" value="SUBMIT">
<a href="/privacy/pop.php" target="_blank" title="View our
privacy policy"><img src="/img/privacy.gif" alt="Privacy Policy" class="privacy"></a>
</td>
</tr>
<tr>
<td> </td>
</tr>
</tbody>
</table>
<input type="hidden" readonly="" name="visitor_ip" value="104.237.193.29" size="100">
<input type="hidden" readonly="" name="referrer_url" id="referrer_url" size="100">
<input type="hidden" readonly="" name="landing_page_url" id="landing_page_url" size="100">
<input type="hidden" readonly="" name="dateoflead" id="dateoflead" value="2022-08-08" size="100">
<input type="hidden" readonly="" name="incoming" id="incoming" value="INCOMING" size="100">
<input type="hidden" readonly="" name="lead_source" id="lead_source" value="veteransupport.us" size="100">
</form>
Text Content
For Immediate Assistance Call 1-800-899-6195 * Home * Asbestos Exposure * Mesothelioma, Lung Cancer & Asbestosis * Veterans Health Administration * Filing A Claim RECEIVE FREE INFORMATION FOR VETERANS WITH MESOTHELIOMA: * Bereavement Counseling * Health Care * Home Loans * Life Insurance * National Cemetery Scheduling Office * Pension Management Center * Special Health Issues * VA Benefits First Name Last Name Mailing Address City State Please Select: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip-code Telephone E-Mail Address Diagnosed with Mesothelioma In addition, please send me the following: Federal Benefits for Dependents & Survivors Understanding and Enrolling in the VHA Disability Claim Forms Comments / Questions VETERANS & MESOTHELIOMA This web site is dedicated to helping those recently diagnosed with mesothelioma, as well as the surviving spouses and dependents of military personnel who died from mesothelioma due to asbestos exposure during their military service. We are grateful for the opportunity to provide quality information and assistance to family members suffering the loss of their husbands, wives, sons, daughters, mothers, and fathers. This includes information on the benefits they are entitled to from the Veteran's Affairs Department. To find out more about what you qualify for in VA benefits and other financial assistance, contact us now. LEARN ABOUT MESOTHELIOMA, LUNG CANCER & ASBESTOSIS Click For More INFORMATION ON THE VETERANS HEALTH ADMINISTRATION Click For More GET HELP FILING A CLAIM & THE NECESSARY PAPERWORK Click For More * Home * Asbestos Exposure * Mesothelioma, Lung Cancer & Asbestosis * Veterans Health Administration * Filing A Claim