CONGRATULATIONS!
Cash all prizes of $599 or less at
your participating Lottery Retailer
PLAYER INFORMATION
SEE PAGE 2 BEFORE COMPLETING FORM
-
-
LAST NAME
DATE OF BIRTH
MONTH
DAY
YEAR
-
-
FIRST NAME
MI
SUFFIX
SSN/TIN
ADDRESS 1
ADDRESS 2
-
CITY
STATE
ZIP CODE
COUNTRY
E-MAIL
-
-
PHONE
I do not have a Social Security Number
I am NOT a U.S. Citizen, and I am NOT a Resident Alien
(Check this box only if you do not have a SSN)
AREA CODE
Are you a Lottery Retailer?
Yes
No
Are you employed by a Lottery Retailer?
Yes
No
Are you related to a Lottery Retailer?
Yes
No
By volunteering to answer the following questions, you will help the Lottery know more about its players. Your responses will not be sold or disclosed to the public.
Other
Which of the following do you consider yourself to be? (Check all that apply)
African American
Asian
Hispanic
White
(specify)
Number of People in Household
Annual Household Income
Under $20,000
$20,000 to $35,000
$35,000 to $50,000
$50,000 to $75,000
Over $75,000
(including yourself):
Education
Did not finish High School
Graduated High School or GED
Some College
Graduated College
Gender
Male
Female
Occupation
(Check all that apply)
Student
Employed
Unemployed
Retired
TICKET INFORMATION
Attach winning Scratchers® ticket to this form with your name and address showing.
Attach winning draw game ticket to this form.
Print your
Print your
name, street,
name, street,
address, city,
address, city,
state and zip
state and zip
code; and
code; and
sign your
sign your
name on the
name on the
back of the
back of the
ticket.
ticket.
TICKET NUMBER
TICKET NUMBER
-
-
-
-
-
18-DIGIT NUMBER ON THE FRONT OF TICKET
18-DIGIT NUMBER ON THE BACK OF TICKET
PRIZE CLAIMED
PRIZE CLAIMED
$
$
I declare, under penalty of perjury and the laws of the State of California, including but not limited to California Penal Code sections 118 and 72, that I am the rightful owner of the winning ticket
on this form, 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 Lottery ticket is in violation of state law and could be liable for criminal penalties.
Winner's Signature (Only one signature, and it must match signature on ticket)
Date
FOR DISTRICT OFFICE USE ONLY
FOR HEADQUARTER OFFICE USE ONLY
PLAYER I.D. CODE
DIST. OFFICE CODE
DATE RECEIVED
POST MARK DATE
CODE(S)
REASON
DRAW DATE
INITIALS
CONTROL NUMBER
RELEASED
INITIALS
FINAL
CRN
(SEE PAGE 2 FOR MORE INFORMATION)
Page 1 of 2
CSL 1242 (R03/15)