GOVERNMENT OF NAGALAND

DIRECTORATE OF STATE LOTTERIES

KOHIMA, NAGALAND
APPLICATION FOR LOTTERY PRIZE CLAIM
PASTE YOUR
Please Tick Below RECENT PASSPORT
Prize Winning Ticket No. : ____________________________ Upto ₹ 10,000/-
SIZE PHOTOGRAPH
Above ₹ 10,000 (NOT OLDER THAN 3
Lottery Name : _________________________________
MONTHS) ALONG

WITH SIGN
Draw No : ___________ Draw Date: _______________

Please Tick Below

To, To,
The Director, The Nodal Officer,
Directorate of Nagaland State Lotteries, Directorate of Nagaland State Lotteries,
Government of Nagaland, 121, Jessore Road South Michael Nagar,
P.R. Hills, Kohima – 797 001 Madhyam Gram, Near National High School,
Kolkata – 700 133

I HEREBY SUBMIT MY PRIZE WINNING TICKET FOR YOUR KIND CONSIDERATION.

Full Name of the Prize winner :_________________________________________________

Permanent Address :__________________________________________________

Father’s / Husband’s Name : _________________________________________________

Profession : _________________________________________________
Name of the Organization : _________________________________________________
Nature of Business : _________________________________________________
Rank of the Prize : _________________________________________________
Prize Amount : _________________________________________________
PAN Number : _________________________________________________
Contact Number : _________________________________________________
Aadhaar No : _________________________________________________
Bank Account Number : _________________________________________________
IFSC Code : _________________________________________________
No. of Claims made in the current FY : _________________________________________________
I enclose herewith the original signed ticket on its reverse side.
I further enclose an Affidavit, Pan Card, one ID proof, 4 passport sized photographs (not older than 3 months) and
a cancelled cheque leaf of my bank account, and I am also aware that the Directorate of State Lotteries can publish
my personal details, such as name, address and my photograph in the newspapers, magazine, television, radio,
social medias & online websites, outdoor Medias Etc.
No changes shall be made in the format while filling this claim form. If any changes are found, the claim will be returned to the respective winner.
Please read the instructions printed on 2nd Page carefully before filling up the form.

Signature:

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 INSTRUCTIONS FOR CLAIM OF PRIZE MONEY

1. All claims of Taxable Prizes should be submitted to The Director, Nagaland State Lotteries/ Nodal
Officer in the prescribed form.
2. Separate Claim forms along with all the documents as mentioned below shall be submitted for each
ticket.
3. Any claim of Non Taxable prize money submitted to the Distributor vide this claim form or its
distribution network (Including Sub Distributor, Area Distributor, Stockists, Sub Stockists, Agents &
Retailers) should be forwarded to the office of the Nodal Officer / The Director of Nagaland State Lotteries.
4. The form should be filled clearly showing the Name of the claimant, Postal Address, Name of the Lottery,
Rank of Prize, Prize Amount, PAN Card, Aadhaar Card, Contact Number and Bank details like Bank
Account Number, IFSC code, Name of the Bank and Branch, cancelled cheque etc. and the number of
claims in the Current Financial Year.
5. Original prize winning ticket with one photocopy duly attested by a Gazetted Officer / Notary Public,
along with four passport size photographs of the claimant, an affidavit of ownership of the prize winning
ticket from any 1stClass Magistrate/Notary Public should also be submitted.
6. Government of Nagaland shall not be liable to pay prizes on tickets lost in postal transit,
defaced/laminated or mutilated.
7. Tampered tickets shall not be entitled to get any prize and any person claiming prize money with a
tampered ticket is liable to be sued in a court of law. Any such claimant shall be liable to appear before the
Director, Nagaland State Lotteries or the Appropriate Authority as and when called for.
8. The Director shall disburse Prize Money for accepted genuine claims after making necessary deduction
of Income Tax etc.
9. Prize money in favour of winners outside Nagaland shall be paid in the form of Demand Draft / RTGS /
Cheque after deducting commission, on drafts and postal charges as applicable.
10. Prize money payable to winners within Nagaland shall be paid in the form of cheque / pay order /
RTGS.
11. The Directorate of State Lotteries may publish the details of the Prize Winners which may include the
name, address and photo of the winner of a prize amount above ₹10,000/- in the newspapers, magazines,
television, radio, social media, online websites, outdoor media etc. The winner who is submitting the
original ticket may accept and fill the claim form accepting the terms and conditions as stipulated therein.
12. Any winner claiming a Prize Amount above ₹ 10,000/- (Taxable Prize Money) more than once, in a
particular Financial Year, shall provide the details of Purchase of such tickets which shall include the Name
of the State in which tickets were purchased, Name of the Seller from whom tickets were purchased along
with his mobile number for verification, or any additional details which may be required before the
disbursement of prizes.
13. Claim form along with original prize winning ticket/s shall be submitted within 30 days from the date
of draw or announcement of result.

Director,
Nagaland State Lotteries
Government of Nagaland

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