document.write("    <!-- Web Form Generator 2.0 -->    <center><form method=\"post\" action=\"http://www.aweber.com/scripts/addlead.pl\">    <input type=\"hidden\" name=\"meta_web_form_id\" value=\"8712782\">    <input type=\"hidden\" name=\"meta_split_id\" value=\"\">    <input type=\"hidden\" name=\"unit\" value=\"drcwi\">    <input type=\"hidden\" name=\"redirect\" value=\"http://www.aweber.com/thankyou-coi.htm?m=audio\" id=\"redirect_6dfbe5f66a690c87e3eb0828026fa7c3\">    <input type=\"hidden\" name=\"meta_redirect_onlist\" value=\"\">    <input type=\"hidden\" name=\"meta_adtracking\" value=\"\">    <input type=\"hidden\" name=\"meta_message\" value=\"1\">    <input type=\"hidden\" name=\"meta_required\" value=\"from,custom I am afraid of,custom I would like to,custom Number of people living in my house (including children),custom My monthly income (before taxes),custom Estimated credit card debt\">    <input type=\"hidden\" name=\"meta_forward_vars\" value=\"0\">    <table>    <tr><td colspan=2><center><div align=\"center\"><h2>FREE CONFIDENTIAL CASE EVALUATION!</h2><div>&nbsp;</div><div><h3>This information is not shared with anyone, we are not a referral website.&nbsp; Attorney Harness will review your information and contact you with the results!</h3><div>&nbsp;</div><div><h4>Take a couple of minutes, complete the form, and I will contact you soon! </h4><div>&nbsp;</div></div></div></div></center></td></tr><tr><td>Name:</td><td><input type=\"text\" name=\"name\" value=\"\" size=\"20\"></td></tr><tr><td>Telephone Number:</td><td><input type=\"text\" name=\"custom Telephone Number\" value=\"\" size=\"20\"></td></tr><tr><td>Email:</td><td><input type=\"text\" name=\"from\" value=\"\" size=\"20\"></td></tr><tr><td>I am afraid of:</td><td><select name=\"custom I am afraid of\"><option value=\"Repossession\">Repossession</option><option value=\"Garnishment\" selected>Garnishment</option><option value=\"Utilities Disconnection\">Utilities Disconnection</option><option value=\"Foreclosure\">Foreclosure</option><option value=\"Eviction\">Eviction</option><option value=\"Other\">Other</option></select></td></tr><tr><td>I would like to:</td><td><select name=\"custom I would like to\"><option value=\"Get rid of bills\">Get rid of bills</option><option value=\"Stop the phone calls\" selected>Stop the phone calls</option><option value=\"Consolidate my bills\">Consolidate my bills</option><option value=\"Reorganize my bills\">Reorganize my bills</option><option value=\"Clean up my credit\">Clean up my credit</option><option value=\"Get caught up on my bills\">Get caught up on my bills</option><option value=\"Protect my stuff\">Protect my stuff</option><option value=\"Other\">Other</option></select></td></tr><tr><td>Number of people living in my house (including children):</td><td><select name=\"custom Number of people living in my house (including children)\"><option value=\" \"> </option><option value=\"1\">1</option><option value=\"2\">2</option><option value=\"3\" selected>3</option><option value=\"4\">4</option><option value=\"5\">5</option><option value=\"6 or more\">6 or more</option></select></td></tr><tr><td>My monthly income (before taxes):</td><td><input type=\"text\" name=\"custom My monthly income (before taxes)\" value=\"$\" size=\"20\"></td></tr><tr><td>Spouses monthly income (before taxes):</td><td><input type=\"text\" name=\"custom Spouses monthly income (before taxes)\" value=\"$\" size=\"20\"></td></tr><tr><td>1st monthly mortgage payment:</td><td><input type=\"text\" name=\"custom 1st monthly mortgage payment\" value=\"$\" size=\"20\"></td></tr><tr><td>1st monthly mortgage payments behind:</td><td><select name=\"custom 1st monthly mortgage payments behind\"><option value=\"0\" selected>0</option><option value=\"1\">1</option><option value=\"2\">2</option><option value=\"3\">3</option><option value=\"4\">4</option><option value=\"5 or more\">5 or more</option></select></td></tr><tr><td>2nd monthly mortgage payment:</td><td><input type=\"text\" name=\"custom 2nd monthly mortgage payment\" value=\"$\" size=\"20\"></td></tr><tr><td>2nd monthly mortgage payments behind:</td><td><select name=\"custom 2nd monthly mortgage payments behind\"><option value=\"0\" selected>0</option><option value=\"1\">1</option><option value=\"2\">2</option><option value=\"3\">3</option><option value=\"4\">4</option><option value=\"5 or more\">5 or more</option></select></td></tr><tr><td>1st car monthly payment:</td><td><input type=\"text\" name=\"custom 1st car payment\" value=\"$\" size=\"20\"></td></tr><tr><td>2nd car monthly payment:</td><td><input type=\"text\" name=\"custom 2nd car monthly payment\" value=\"$\" size=\"20\"></td></tr><tr><td>Estimated total credit card bills:</td><td><input type=\"text\" name=\"custom Estimated credit card debt\" value=\"$\" size=\"20\"></td></tr><tr><td>Estimated medical bills:</td><td><input type=\"text\" name=\"custom Estimated medical bills\" value=\"$\" size=\"20\"></td></tr><tr><td>Estimated back income tax bills:</td><td><input type=\"text\" name=\"custom Estimated back income tax bills\" value=\"$\" size=\"20\"></td></tr><tr><td>WeEnergies bill:</td><td><input type=\"text\" name=\"custom WeEnergies bill\" value=\"$\" size=\"20\"></td></tr>        <tr><td colspan=2><center><div><span>&nbsp;</span></div><div><span>Your submission is a great first step toward financial freedom.&nbsp; However, it does not constitute an attorney-client relationship between you and Attorney Harness.&nbsp; I cannot represent you until we agree on the scope of my representation.&nbsp; I am a debt relief agency.&nbsp; I advise people regarding their rights under FDCPA, FCRA, bankruptcy codes, and state amortization statutes</span></div><div><span>&nbsp;<br></span>&nbsp;</div></center></td></tr>    <tr><td align=\"center\" colspan=\"2\"><input type=\"submit\" name=\"submit\" value=\"Submit\"></td></tr>    </table>    </form>        </center>");

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