HTML

<form action='$SELF_URL' METHOD=POST>
  <input type='hidden' name='index' value='$index'>

  <div class='box box-theme form-horizontal '>
    <div class='box-header with-border'>
      <h4 class="box-title table-caption">_{FILTERS}_</h4>
      <div class="box-tools pull-right">
        <button type="button" class="btn btn-default btn-xs" data-widget="collapse">
          <i class="fa fa-minus"></i></button>
      </div>
    </div>

    <div class='box-body'>
      <div class="row align-items-center">
        <div class="col-sm-12 col-md-6">
          <div class='form-group'>
            <label class='col-md-3 control-label'>_{DATE}_ </label>
            <div class='col-md-9'>
              %DATE_RANGE%
            </div>
          </div>
        </div>
        <div class="col-sm-12 col-md-6">
          <div class='form-group' style='display: %HIDE_SOURCE_SELECT%'>
            <label class='col-md-3 control-label'>_{SOURCE}_</label>
            <div class='col-md-9'>
              %SOURCE_SELECT%
            </div>
          </div>
        </div>
      </div>
    </div>
    <div class='box-footer'>
      <input type='submit' class='btn btn-primary btn-block' value='_{FILTER_LEADS}_' name='filter'>
    </div>
  </div>
</form>