Winner Claim Form

INSTRUCTIONS

The Wisconsin Lottery

www.wilottery.com

Reference Number

Fill out and sign the back of your winning ticket in blue or black ink. Fill out the Claimant Information blocks as they apply to you and your winnings. Sign Line 17. Read the information on the back of this form. To receive winnings by mail, please complete and send along with ticket(s) to: Prize Payments, Madison WI 53774. Keep a copy of your ticket and the pink copy of this form for your records and reference. NOTE: The Wisconsin Lottery only makes payment on the original ticket. On-line tickets $5,000 or more may take several hours to process and it is recommended that you call in advance and arrive no later than 2 p.m. on the day you claim your prize. You may call (608) 267-2839 for further information. You must notify validation staff if you plan to cash your check today (see back of this form). There is a 2 hour delay for same day cashing of lottery checks.

Please staple winning instant or on-line ticket(s) to the top copy of this form. Do not use glue or tape. Please do not staple through winning numbers or play spots on ticket.

TICKET INFORMATION

TICKET(S) $600 OR GREATER

1. Instant Ticket Validation Number (15-digit number on the FRONT of scratch ticket) 2. Instant Ticket Number (13-digit number on the BACK of scratch ticket)

3. On-Line Ticket Number

On-Line Tickets
(for Lottery use $5,000 or more)

TICKET(S) LESS THAN $600

4. Number of Tickets Submitted 5. Total Prize Amount Claimed

< 90 days ALL TICKETS > 90 days Pass CF Test Fails CF Test

.0 0

6. Is prize being claimed by more than one person?

No

Yes If so, see back of form.

CLAIMANT INFORMATION

7. Last Name, First Name, M.I. 8. Birth Date

9. Street Address

Month 10. County

Day

Year

11. City

12. Country (if not United States)

13. State

14. Zip Code

14a. Daytime Phone Number (include area code)

14b. Alternate Phone Number (include area code)

15. Social Security Number

16. Winners Release Authorization

Consistent with State of Wisconsin Open Records law, s. 19.31 to 19.39, Stats., the Lottery may use your name, likeness and/or town of residence, without compensation to you, in public information efforts. Upon claiming your prize, you are releasing the Wisconsin Lottery and its representatives from any and all liability which may result from the use or release of the information.
I have read the instructions for this form and understand my rights and responsibilities as a Lottery winner. I hereby certify that I am 18 years of age or older and that all information provided is true and correct. I understand that any person who, with intent to defraud, falsely makes, alters, forges, or counterfeits a state lottery ticket is in violation of state criminal law. If I choose not to provide my social security number, my winnings will be taxed at a higher rate, which may affect the amount or timing of any prize paid.
17. Winners Signature (only one will be accepted) Date

VALIDATION OFFICE USE ONLY

Game Number Winner Initials Lottery Initials (Receipt of check) (Received by) Office Date Received

Winnings $1,000 or more Identification: Driver Lic. # Claimant Photo? Yes No

Wisconsin Department of Revenue

Exp.

Instructions
Mandatory Information (must be provided to receive your check) You must provide your name, birth date, address, city, state, and zip code. We ask that you also provide your social security number to facilitate the payment of your prize (items 7, 8, 9, 11, 13, 14, 15). Sign this form (item 17) and the back of your instant or on-line ticket. Note: Item 15 Wisconsin Statutes 565.30(5t) require the Lottery to check social security numbers with the Department of Revenue for claimants of all prizes of $1,000 or more. If your prize is $1,000 or more, and you do not, or cannot, provide your social security number, you will not receive your check at this time, until after we have researched the Department of Revenue delinquency files. In addition, federal back-up withholding will be deducted from all prizes $600 or greater if your social security number is not provided. Without a social security number, only checks $600 to $999 will be received on the day processed and will have federal back-up withholding deducted from the gross amount of the prize paid. All other information requested on this form is voluntary. If you have any questions regarding the validation of your winning ticket, please call the Lottery Validations Office at (608) 267-2839. Note: Tickets are void if stolen, unissued, mutilated, altered, unreadable, counterfeit, misregistered, defective, mis-printed or otherwise fail validation tests. All tickets submitted to the Wisconsin Lottery become property of the Lottery and will not be returned. All tickets are subject to the Features and Procedures of the given game. Features and Procedures for individual games are available upon request.

NOTES: Item 6 Multiple-Owned Tickets. To share a Lottery prize ALL of the following must be completed: The Lottery will recognize more than one claimant claiming a prize from a single ticket only when item 6 on the front of this form is answered yes and each claimant in the group completes a claim form. A court order is required for any prize for which there is more than one claimant. The court order must be accompanied by a separate winner claim form for each prize claimant. Multiple-owned tickets must be processed at the Madison office. This process may take up to two weeks after the court order is received. A person claiming a prize or part of a prize is subject to withholding, pursuant to Wis. Stats. 565.30(5t), the amount to be withheld shall be deducted from the prize claimants proportionate share of the total prize. For tax reporting purposes, the Lottery will recognize only those individuals who have filed a claim form for a particular prize. Once a prize has been paid, the Lottery will not accept requests to add persons to the list of individuals who will share a prize. Item 7 Enter only one persons name for item. Multiple-owned tickets must be processed at the Madison office (see Item 6).

Item 15 Disclosure of Social Security Number. Your social security number will be used to report the amount of your winnings to the Internal Revenue Service, as required under Federal law. Your prize winnings are subject to both federal and state income tax withhold ing. Federal taxes (at the current rate) are automatically deducted from prize payments of $5,001 or more. State taxes (at the current rate) are automatically deducted from prize payments of $2,000 or more. This may not be your entire tax liability. Please consult your tax advisor for further assistance. Withholding rates are subject to change. (See mandatory information regarding not providing a social security number.) Item 16 Winners release authorization. Consistent with State of Wisconsin Open Records law, s. 19.31 to 19.39, Stats., the Lottery may use your name, likeness and/or town of residence, in public information efforts without compensation to you. Upon claiming your prize, you release the Wisconsin Lottery and its representa tives from any and all liability which may result from the use or release of the information.

On-line tickets $5,000 or more may take several hours to process. Please call the office ahead of your arrival time. You must arrive by 2:00 p.m. to assure payment that day. If you are CASHING YOUR CHECK TODAY, you must alert validation staff when you receive your check, and they will notify the bank. There is a 2 hour delay for same day cashing of Lottery checks.

You may call (608) 267-2839 for further information. Jackpot Prizes resulting in annuity or cash option choices must be claimed at the Madison office. Please contact Lottery Player Relations at (608) 261-4916 prior to claiming your ticket.