Lottery Results Verification Form
Please complete all fields below to verify your lottery results. All information provided will be used solely for claim verification purposes.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Lottery Draw Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Lottery Ticket Number
*
Claim Reference Number (if provided)
Location of Ticket Purchase (City/Store/Online)
*
Type of Lottery Game
*
Please Select
Standard Draw
Instant Win
Scratch Card
Online Entry
Other
Claimed Prize Amount
*
Upload Ticket Image or Proof of Entry
*
Upload a File
Drag and drop files here
Choose a file
Cancel
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Verify Results
Should be Empty: