WINNER CLAIM FORM – Oregon Lottery

Use this shape when claiming a fetching slate through the mail or in person at the Lottery function. Do not use this form for prizes paid by retailers. INSTRUCTIONS TO WINNER CLaImIng aside mail : before completing this form, please read the information on the second of the yellow replicate. Sign the binding of the ticket ( one key signature only ). after completing items 1-13, you must read all information in detail 14, polarity and date. mail blank copy of the completed form and the original fetching slate for processing to : Oregon Lottery PO Box 14515 Salem, OR 97309 CLaImIng In PERSOn : bring the succeed tag for processing to : 500 Airport Rd. SE Salem, OR 97301 Keep scandalmongering copy of this form. 1. name 3. address Registered Mail Recommended Take exit 253 off I-5 and follow Lottery signs WINNER IN FORM ATION last Name First Name Middle Initial Home # Including Area Code Month Day Year Daytime # Including Area Code CLaIm number 4. City 5. State 6. Zip – 7. SSn – – 10. phone # – – 12. Prize Claimed $ 14. Winner Declaration 8. birth Date – – Under penalty of police, I declare that the mention, address, and taxpayer recognition issue which I have furnished, correctly identify me as the recipient role and true owner of the loot claimed, and that the ticket attached to this claim has not been falsely made, change, forged, or counterfeited. I am not the spouse, child, brother, sister, or parent of any extremity of the Lottery Commission, the Director, the assistant Directors, or any employee of the Oregon Lottery. I have read and understand the information on the front and back of this form. claimant ’ mho signature Date / / any person who, with intent to defraud, falsely makes, alters, forges, or counterfeits a department of state lottery ticket is guilty of a class C felony penal by up to 5 years in prison and a finely of $ 100,000. ORS 165.013. 13. – – insert TICKET FACE-UP HERE ( Did you sign your tag ? ) then remove record and seal WINNER CLAIM FORM For prizes paid directly by the Oregon Lottery ® Verified Prize Amount : # of Tickets/Type : Security Review : payment ID/Initials : Check # : Issued by : date : / / mail WaLK-In CLaIm number State Issued Revised : 02/09 White Copy : Lottery jaundiced copy : For Your Records OSL Item # : 0002 11. Driver ’ s License # 2. sex 9. U.S. Citizen Have all tickets been submitted that were purchased for this game/ drawing that have the same numbers selected ( i.e. an identical ticket ) ? FOR LOTTERY USE ONLY M F YES NO YES NO N/A Received by : date : / /

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Category : Lottery

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