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(STAPLE TICKET HERE

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GOVERNMENT OF SIKKIM ONLINE LOTTERY - WINNER CLAIM FORM
(Please read instructions overleaf)
PLEASE FILL IN WITH CAPITAL LETTERS your name, address and phone number on the back
your ticket- YOU MUST SIGN YOUR TICKET. Any winning Numbers-game ticket of upto
Rs. 10,000/- can be claimed at any licensed numbers-game lottery retailer, regardless of where the
ticket was purchased, provided their cash balances are adequate.
RETAIN A PHOTOCOPY of the front and back of your winning ticket and of this completed form
for your personal records. Staple the ticket to the top right corner of this form and read
instructions overleaf for getting your prize amount.
___________________

1. FIRST NAME

___________________

2. MIDDLE NAME

__________________

3. SURNAME

4.DATE OF BIRTH -________________ 5. GENDER (M/F) -___________
(dd-mm-yy)
6. MAILING ADDRESS
__________________________________________________________________________________
__________________________________________________________________________________
CITY ______________________ STATE ________________ PIN CODE _____________
7. (i) Name of Bank
______________________________
(ii) Name of Branch _______________________________________________
(iii) Branch Code No. ______________________________________________
8. ACCOUNT NO. __________________________
9. PAN NO. (Compulsory) ____________________
10. Contact : (i) Telephone No. __________________
(ii) Mobile No. ____________________
(iii) E-Mail _______________________________________
11. Are you an INDIAN RESIDENT (Y/N) ___________________
12. TICKE T PURCHASED ON ___________________ 13. AMOUNT OF PRIZE ______________
(dd-mm-yy)
14.PROOF OF IDENTITY ATTACHED (Y/N)
PASSPORT COPY/ RATION CARD /VOTERS ID CARD / ANY OTHER _________________________
( Strike out whatever is not applicable)

including forfeiting the prize claimed and to the liability of offences under Indian law. altered.) I hereby solemnly declare that I have read the instructions printed overleaf and state that I am over the age of 18 years and the information supplied above. I undertake to be liable for any falsity in information provided or misrepresentation made herein and agree to bind myself to any penalty that Government of Sikkim. that appears on the ticket. my locality and prize amount become public information. ___________________________________________ (Exact no. I agree that by signing this form and claiming the prize. I further declare that the ticket has not been falsely made. my name. is true and correct to my knowledge.15.GAME /TICKET INFORMATION Numbers played ______________________ (separate numbers with hyphens) Ticket FRONT Serial No. forged or counterfeited. in its sole discretion may impose. Claimant's Signature __________________ Date ________________ FOR OFFICE USE ONLY Received by :_____________ Date : _______________ Checked by :______________ Date: of forwarding To Treasury department .

11. 15. 8. address and signature on back of the ticket.Kolkata. The processing of documents received from the Claimant will be done within 90 working days from the receipt thereof. The prize amount shall be claimed by submitting a claim form along wit h 3 passport size photographs duly at tested and supported by an affidavit sworn in before a first class magistrate in person or through any scheduled/nationalized bank. 18.10.India. Such payment will be subject to Tax deduction at source. 6. Incomplete forms shall be considered invalid. 3. Tel: 022-24815671 Kolkata: Flat No. Sikkim State Lotteries. 19. you may contact any Playwin office. Dr. photograph and other information for promotional and publicity purposes and t he Claimant agrees to the same without any further claim for payment. 20. Claimant shall not indulge in any press and/or media interviews without the prior permission from Playwin. 12. Road. Indicate the prize amount legibly.Harrington Mansion. Persons/ entities disqualified by law are not eligible to the prize money.700071.Sikkim State Lotteries. Payment will be made after verification regarding genuineness of the ticket to the claimant of the ticket. 13. Government of Sikkim/ Playwin is not responsible for any non-delivery of mails. 16. Mumbai . Government of Sikkim or Playwin may advise you to submit more information over and above mentioned in the claim form. 10. B. Ho Chi Minh Sarani. The prize amount will be paid directly by the government of Sikkim and sent t o the address in the claim form. 5. You are required t o approach any retailer appointed by PAN India Network Ltd (Playwin) and get your ticket validated. 2.8. by demand draft/cherub after deducting the tax as applicable On the date. 11. For any assistance required. Put your name. Prize amount not exceeding Rupees Ten Thousand (Rs. 14.400 018. 7. Tel:033-22822660/61 . Worli. ticket And proof of identity to the absolute discretion of Government of Sikkim. Complete the claim form and follow the instructions provided. Claimant will be responsible to resolve any dispute regarding the claim on prize money and Government of Sikkim/Playwin shall not bear any responsibility for the same. lost in transit or non-receipt of forms dispatched by the Claimant. Continental Building. 000/. 17.shall be paid directly by the Director . Gangtok 737101 by registered/ insured post at claimant’s own risk. Decision of Government of Sikkim shall be final and binding on t he Claimant. Prize should be claimed within 90 days from its declaration.10. Prize amount above Rupees Ten Thousand (Rs. Playwin is entitled t o use the winner's name. 9.INSTRUCTIONS 1. The winning ticket and claim form must be completed in the name of one individual or legal entity. PAN India Network Ltd: Mumbai: 135. Prizes will be given only on complete physical verification of the document s. The claim ma y be sent to Director. 4. A. Any dispute regarding the payment of prize shall be subject to the exclusive jurisdiction of the Courts in Gangtok only. 000) shall be paid by the Retailer.