(on Stamp paper)

AFFIDAVIT

Affidavit of Mr./Mrs.……………………. s/o Mr.…………………, aged about ………..years

residing at…………………………………………………………….……………………………………………………………

………………………………………………………do hereby solemnly affirm and declare as:

1. That I am at residing at ……………………………………………….

2. That I have purchased the ticket “<<Game Name>>” of Government of

“<<Name of Government>>” through ITZ Cash Card (Card No. ……..)
and my ticket number is <<16 digit TSN No>>

3. That I have matched……… numbers of “<<Game Name>>” draw held

on………………….

4. Bank Details: Name of the ………………………………………… Branch …………………… A/c

no ……………………Type of A/c…………………………

5. That the above statements made by me are true and correct.

DEPONENT

VERIFICATION

Verified at…………………………(Name of the city and on day/month/year)

That the contents of the above paragraphs 1 to 4 are true and correct
to my knowledge based on facts.

DEPONENT

Attested Attested Attested

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