First Name
Last Name
Date of Birth
MI
Suffix
SSN / TIN
Address 1
Address 2
City
State
ZIP Code
Country
Email
Phone Number
I am a Lottery RetailerI am employed by a Lottery RetailerI am related to a Lottery Retailer
I do not have a Social Security NumberI am not a U.S. Citizen, and I am not a Resident Alien
Claim Number
Prize Claim: $
I declare, under penalty of perjury under the laws of the States, including but not limited to United States Penal Code ยงยง 118 and 72, that I am the rightful owner of the ticket on this form, that I am 18 years of age or older, and that all information provided is true and correct. I understand that any person who, with intent to defraud, falsely makes, alters, forges or counterfeits a Lottery ticket is in violation of state law and could be liable for criminal penalties.
Claimant Signature
(Only one signature, and it must match signature on ticket)
Date
By volunteering to answer the following questions, you will help the Lottery know more about its players. The voluntary information that you provide regarding your ethnicity, household income, gender, and household composition will be used only by the Lottery to conduct internal demographic analyses (which may be completed by agents and contractors).
Which of the following do you consider yourself to be?
(Check all that apply)
African AmericanAsianHispanicWhiteOther
Annual Household Income
Under $30,000$30,000 TO $49,999$50,000 TO $99,999$100,000 TO $149,999$150,000 or more
Number of People in Household (including yourself):
Gender
MaleFemaleNonbinary
