Directorate of Punjab state lotteries, Chandigarh

S.C.O. No. 106- 108, Sector 17-D, Chandigarh

Claim form for the prize winner (s) of Punjab state

-------------------------------------Held on----------------------------------------1. Name of the winner (S)

___________________________________

(In Block Letters)

2. Minor or Major

___________________________________

3. Fathers/ Husband Name

___________________________________

4. Permanent Address

___________________________________

(In Block Letters)

5. Present Address

___________________________________

6. Telephone/ Mobile Number

___________________________________

7. Occupation

___________________________________

8. Income Tax Circle

___________________________________

9. Pan Number

___________________________________

10. Prize winning Ticket/ Coupon Number

11. Date of Draw

___________________________________

12. Amount of Prize

___________________________________

Date

Signature of the Claimant

Advance Receipt
Received a sum of Rs. _______________ Rs.___________________________ from
Director Punjab State Lotteries, Chandigarh being the prize amount won by Tickect No.
__________________________ of Punjab State
__________________________________________.
This Draw was held on __________________________________________.

Signature of the Claimant

(With Revenue Stamp)
Instructions
1. Affix three passport size Photographs with Claim Form out of which two should be duly
attested by 1st Class Magistrate/ Notary Public/ Oath Commissioner any Gazetted
Officers.
2. If the Claimant is Minor then an Affidavit from the National Guardian/ Parent should be
attached with the Claim Form.
3. If the claim is not claimed within the prescribed period (30 days from the date of Gazette
Notification) then reasons of this on an Affidavit should be attached with the Claim Form