Lottery Claim Form

Lottery Claim Form
Claimant Information
Please make sure all provided information is accurate and your data will be kept safely
Name
First NameLast Name
Birth Date
MonthDayYear
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Please select the options that best apply to your situation?
Ticket Information
Please make sure all information is accurate
Ticket Number
13-digits number for Scratchers and 18-digits number for Draw Game is located on front of the ticket
Upload Ticket
Sign your name on the back of the original ticket with your name and address information and upload a scanned copy here. Also, scan the front of your ticket and upload it here.
Cancelof
Prize Claim
Please type the exact number
Acknowledgment & Consent
I declare that I am the rightful owner of the ticket on this form, that I am 18 years and older, and that all information provided above are true and are given with my full consent.
I understand that, any person with intent to defraud, falsely makes, alters, forges or counterfiets a Lottery ticket is in violation of state law and could be liable for criminal penalties.
Failure to provide your personal information, contact details, or the accurate ticket information might prevent or delay the processing your prize claim.
Lottery prizes are not subject to Sate Income Tax.
Date
MonthDayYear
Date
Claimant Signature
Clear
Should be Empty: