WINNER CLAIM FORM - Wyoming Lottery

WINNER CLAIM FORM

CLAIMANT INFORMATION

1. Legal Name of Winner

First

Last

2. Social Security Number or Federal Taxpayer Identification Number

?

?

3. Date of Birth (MM-DD-YYYY)

?

?

ATTACH TICKET HERE

4. Citizenship (Check One)

1. Sign back of ticket(s) 2. Send entire ticket (do not cut or damage ticket) 3. Staple ticket to claim form (do not staple through

any numbers or play spots on ticket(s)) 4. Attach 2 forms of Government issued

identification. One must be a copy of your Social Security Card, the other, a valid, picture ID 5. Retain a copy for your records. 6. Non-resident Alien-Must provide Tax ID number

U.S. Citizen ? MUST provide Social Security Number Resident Alien ? MUST provide Social Security Number Non-resident Alien ? please provide country of Citizenship:

_________________________________________________

5. Mailing Address/Number/Street

Apt/Suite # (if any)

6. City 9. County 11. Email

7. State

10. Phone

?

8. Zip Code

?

12. Identification Type: Driver's License Passport Other: ______________

Number

State of Issuance

ALoretteyroyuparondeumctpsl?oyee oYreoswner oNf oany business that sells

If Yes: Employer: ______________________________ Address: _____________________________________ Contact: _______________ Number:_______________

ACKNOWLEDGMENT AND CERTIFICATION

I declare, under penalty of perjury, that I am 18 years of age or older and that I am eligible to claim a lottery prize pursuant to the laws and regulations governing the operation of the Wyoming Lottery Corporation, and that all information provided herein is true and accurate to the best of my knowledge. Further, I declare I have legally obtained rights to the prize I am claiming, that I am the lawful owner, and that I am not legally prohibited by law from claiming a prize. I understand that any person who falsely makes, alters, forges, conceals their true identity upon, steals, embezzles, makes a fraudulent or illegal claim with, or counterfeits a Wyoming Lottery ticket may be guilty of one or more crimes pursuant to W.S. 9-17-122. I agree to indemnify and hold harmless the Wyoming Lottery Corporation for any loss or expense it might incur if any of the information I have provided is not true and accurate, or for any prize claim which is in violation of law.

Claimant's Signature:________________________________________________________________________ Date:______________________________

LOTTERY USE ONLY

Security Verification Checked:

Date of Claim Claim No. Serial No. Check No.

Received By Security Approved

Prize Amount Date of Check

Approved Government forms of Identification shall include: A Government Identification card (ie. Drivers' License, State Issued Identification Card, Military Identification and US passport). A Social Security Card must be produced to verify the Social Security Number. A Medicare card may be substituted for the SS Card as long as the owner of the card has his/her SSN present on the card.

THE WYOMING LOTTERY CORPORATION ? 1620 CENTRAL AVE, STE 100, CHEYENNE, WY 82001 ? 307.432.9300 ?

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