Full Form Host and Post Leads - Data Required: First Name Last Name Email DOB and/or Age Phone Address State Zip Code Source and any Sub Source Info Jornaya/Trusted Form Cert IP Address of Lead URL of Opt-In Timestamp of Lead Opt-In Targeting: Age: 53-64 only States: All states accepted except Montana, North Dakota, South Dakota, Wyoming, New Mexico, Alaska, Puerto Rico, and US Territories Qualifying Questions: Do you have a disability that prevents you from working? YES Do you expect to be out of work for at least 12 months? YES Are you currently receiving Social Security Disability benefits? NO Is an attorney helping you with your case? NO Have you had a full time job at any time within the last 5 years? YES Have you worked full time for 5 of the last 10 years? YES