Lottery Winnings Agreement Waiver

Lottery Winnings Agreement Waiver
Complete this form to acknowledge and agree to the terms regarding the distribution or waiver of lottery winnings.
Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Relation to Other Parties (if applicable)
Name of Lottery
Lottery Drawing Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Ticket Number or Identifier
Agreed Amount or Percentage of Winnings (if applicable)
Signature
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Date of Agreement
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: