LOTTO SUBSCRIPTION APPLICATION - New York …

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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