LOTTO SUBSCRIPTION APPLICATION - New York …
[Pages:2]LOTTO SUBSCRIPTION APPLICATION
New York Lottery Subscription Program PO Box 7590 Schenectady, NY 12301-7590
1. SUBSCRIBER INFORMATION - Please print clearly
IMPORTANT: Subscriber must provide a New York State mailing address.
4 EASY STEPS
1. Complete ALL Subscriber Information One name only.
2. Pick your plan - Choose ONE plan only ... 2, 4, or 6 games played twice a week.
3. CIRCLE 6 numbers in each game you have played OR select the Quick Pick option for random computer generated numbers that will remain in effect for the length of your plan
4. PAYMENT - Enclose check or money order for the exact amount of your plan (see Step 2 for the cost of the plan you've chosen.
Last Name (Subscriber or Group Representative)
First Name
Initial
Street Address
Street Address
City
N Y
State
Zip Code
Area Code Telephone Number
Social Security Number
CIRCLE YES OR NO FOR EACH QUESTION
Are you a New York City resident?
Date of Birth (mm/dd/yyyy)
E-mail Address
YES NO
GROUP - If you are representing a group, enter the group name below and list group members on back. Are you a Yonkers resident?
YES NO
Allow approximately 15 business days for processing. A Confirmation will be mailed prior to the effective date of your subscription. Completion of this application certifies that each purchaser is 18 years of age or older.
A3100
2. PICK YOUR PLAN CHECK ONE BOX ONLY - 2 drawings per week (Wed. & Sat.)
2 GAMES PER DRAWING
4 GAMES PER DRAWING
6 GAMES PER DRAWING
52 DRAWS
$52
104 DRAWS
$104
52 DRAWS
$104
104 DRAWS
$208
52 DRAWS
$156
104 DRAWS
$312
3. CIRCLE 6 NUMBERS OR CHOOSE QUICK PICK
GAME 1
QUICK PICK
1 2 3 4 5 6 7 8 9 10
GAME 3
QUICK PICK
1 2 3 4 5 6 7 8 9 10
GAME 5
QUICK PICK
1 2 3 4 5 6 7 8 9 10
11 12 13 14 15 16 17 18 19 20
11 12 13 14 15 16 17 18 19 20 11 12 13 14 15 16 17 18 19 20
21 22 23 24 25 26 27 28 29 30
21 22 23 24 25 26 27 28 29 30 21 22 23 24 25 26 27 28 29 30
31 32 33 34 35 36 37 38 39 40
31 32 33 34 35 36 37 38 39 40 31 32 33 34 35 36 37 38 39 40
41 42 43 44 45 46 47 48 49 50
41 42 43 44 45 46 47 48 49 50 41 42 43 44 45 46 47 48 49 50
51 52 53 54 55 56 57 58 59
51 52 53 54 55 56 57 58 59
51 52 53 54 55 56 57 58 59
GAME 2
QUICK PICK
1 2 3 4 5 6 7 8 9 10
GAME 4
QUICK PICK
1 2 3 4 5 6 7 8 9 10
GAME 6
QUICK PICK
1 2 3 4 5 6 7 8 9 10
11 12 13 14 15 16 17 18 19 20
11 12 13 14 15 16 17 18 19 20 11 12 13 14 15 16 17 18 19 20
21 22 23 24 25 26 27 28 29 30
21 22 23 24 25 26 27 28 29 30 21 22 23 24 25 26 27 28 29 30
31 32 33 34 35 36 37 38 39 40
31 32 33 34 35 36 37 38 39 40 31 32 33 34 35 36 37 38 39 40
41 42 43 44 45 46 47 48 49 50
41 42 43 44 45 46 47 48 49 50 41 42 43 44 45 46 47 48 49 50
51 52 53 54 55 56 57 58 59
51 52 53 54 55 56 57 58 59
51 52 53 54 55 56 57 58 59
NOTE: If fewer than 6 numbers are circled in any game, additional number(s) will be randomly assigned to process the application. Numbers chosen in excess of what is required to process the application will be disregarded.
REV 1/11
4.
PAYMENT CHECK OR MONEY ORDER
Check or money order (payable to NY Lottery) enclosed for $ ___________ covering my subscription. Check or money order number: ____________
IMPORTANT: Subscriber or Group Representative must provide a mailing address within New York State since Federal Law prohibits mailing a Lottery confirmation across state lines.
COMPLETE ONLY IF GROUP
Group Information - please print clearly
Starting with the group representative, list the names, addresses and social security numbers of all group members in the spaces below. A maximum of 10 members per group is allowed. Be sure to mark Yes or No to both of the questions for each group member. 1. Is the member a New York City resident? 2. Is the member a Yonkers resident?
Prizes of $600 or less will be paid to the Group Representative for distribution to the group members. Prizes greater than $600 will be divided in equal shares and paid to each member of the group. The Lottery is not responsible for disputes between or among group members.
Member Name
Address
City
1.
ST ZIP NY
Social Security Question
Number
1
2
Y NYN
2.
3.
4.
5.
6.
7.
8.
9.
10.
Prizes/Chances of Winning Lotto
Lotto Prize Winning Numbers Chances of Winning Chances of Winning LevelMatched Per Game on one Game Panel on a $1.00 Play
First
6
1: 45,057,474.00 1: 22,528,737.00
Second 5 + Bonus 1: 7,509,579.00 1: 3,754,789.50
Third
5
1: 144,414.98 1: 72,207.49
Fourth
4
1: 2,179.85 1: 1,089.92
Fifth
3 of 6
1:
96.17 1:
48.8
Overall Odds of Winning on a $1 Wager - 1:46.02
Lotto Jackpot Prize Payment
Jackpot winners must make arrangements to receive their prize and are required to have a media announcement. If you win the Jackpot, you will have 60 days from the date the Lottery provides you with a Jackpot Claim Form to decide if you prefer 26 Graduated Annual Payments or a Lump Sum Cash Payment. If you choose the Lump Sum you will receive the estimated present value of the advertised Jackpot. This amount will be less than the advertised Jackpot.
Taxes
The Lottery is required to report and withhold taxes according to the regulations of the Internal Revenue Service and the New York State Department of Tax and Finance.
Prize Information
If you match all 6 numbers and win the jackpot, you will be notified by a Lottery representative to make arrangements to receive your prize. Prizes over $600 will be mailed to you. Smaller prizes will be automatically credited to your Subscription Center account. You can view your prize winnings through the Subscription Center at . You will be able to use your prize credits to reduce the cost of your next subscription purchase or request a cash-out of your prize credits at any time.
Revisions
The New York Lottery reserves the right to suspend or cancel any drawing or the game itself, change the prize structure, frequency of draws or draw dates. In the event of such a change, all subscribers will receive participation in a revised game, equivalent in value to the remainder of their subscription, or a refund, at the sole option of the Lottery.
Personal Information Notice
To process your prize claim, you authorize the New York Lottery to collect personal information about you. You authorize the New York Lottery to use and release certain personal information, including your name, hometown and any photograph, video or audio recording, in any medium (including but not limited to newspaper, television, radio and internet), for purposes of marketing, advertising or purposes of the New York Lottery. If you do not provide all or any part of the personal information requested, your claim might be denied and you might not be awarded a prize. The New York Lottery is requesting this personal information pursuant to its authority under Tax Law Section 1604 to operate and administer the New York Lottery which includes the marketing and advertising of the New York Lottery and the identification of the person entitled to a prize award. Your personal information will be maintained by the Lottery's Prize Payment Unit. The Director of Prize Payment is the custodian of such records and may be contacted by mail at One Broadway Center, POB 7533, Schenectady, New York 12301-7533 or by phone at (518) 388-3370.
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