<form class="mt-40 mb-40">
  <input type="hidden" id="id" value="">
  <input type="hidden" id="no_telp" value="">
  <label data-lang="email" for="email">Email</label>
  <input type="text" id="email_4" name="email_4" value="" placeholder="example@email.com">
  <label data-lang="reason" for="comment">Reason</label>
  <textarea id="reason_4" data-ph_lang="comment" placeholder="Your comment here" id="comment">
  </textarea>
  <a href="#" data-lang="save" id="account_delete_button" class="button button-fill">Save</a>
</form>