Winner Claim Form - Maine State Lottery
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1
2For office use only
Check No.:__________________
Claim No.:__________________
WINNER CLAIM FORM
Please read the instructions on this form carefully (see page 2 for more detailed instructions). This form must
be completed fully and legibly. For questions about claiming your prize, please contact our office at (207) 287-
3721 or MaineLottery@Maine.gov.
Claimant Information:
Instructions for claiming your winnings:
____________________________________________________
Last Name
First Name
Middle Initial
Please sign the back of your ticket, complete
the claim form as well as signing and dating
____________________________________________________
at the bottom.
Please mail original and
Street, Rural Route or PO Box
signed ticket together with your claim form.
We strongly encourage you to send your
____________________________________________________
winning ticket by certified or express mail or
City, State and Zip Code
by another means to track your winning
ticket delivery to this office.
___________________________
______________________
Social Security or FEIN
Daytime Telephone #
Staple Winning Ticket Here
__________________________________ ________________
Email Address
Date of Birth
Your ticket is not a winner until
validated by the Maine State
Lottery.
For Office Use Only
Amount of Prize over $5000: _______________________
Federal Tax Withheld: ____________________________
Our office addresses:
State Tax Withheld: ______________________________
Physical:
10 Water Street
Hallowell, ME 04347
Check Amount: _________________________________
Mailing:
8 State House Station
Augusta, ME 04333-0008
Certification: Under penalty of perjury, I hereby declare that, to the best of my knowledge and belief, the
name, address, and social security number or FEIN provided correctly identifies me as the claimant of this prize
and that the claimant is not prohibited by law from purchasing a lottery ticket. I understand that any person
who, with the intent to defraud, falsely presents for payment a forged, counterfeit, or altered ticket is in
violation of state law and may be prosecuted or will be referred for prosecution.
_______________________________________________
______________________________
Signature
Date
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