Fillable Ca Lottery Winner Claim Form (Page 2 of 2) in pdf

PLEASE READ ALL INFORMATION AND INSTRUCTIONS

BEFORE COMPLETING CLAIM FORM

Failure to provide your original signed winning ticket, social security number, date of birth, name, and complete address (including apartment or space

number), city, state, zip code, and phone number may delay or prevent the Lottery from processing your prize claim or result in additional federal taxes

withheld from your prize. Lottery prizes are not subject to California state income tax.

If you are not a U.S. citizen or a resident alien, the Lottery is required by federal tax law to withhold additional taxes from your prize. The Lottery is

required to withhold federal taxes of 25% for U.S. citizens and resident aliens providing a social security number, and 28% for U.S. citizens and

resident aliens not providing a social security number. Players who select "I am NOT a U.S. Citizen and I am NOT a Resident Alien" box will have 30%

withheld from all prizes. Federal tax rates are subject to change.

1. Print your name, street address, city, state, and zip code on the back of the ticket.

2. Sign your name on the back of the ticket.

3. Complete the Player Information and Ticket Information sections on the first page of this form.

4. Sign the first page of this form with ink. (ONLY ONE SIGNATURE IS PERMITTED)

5. Staple your ticket to the front of this form.

KEEP A COPY OF THIS FORM AND A COPY OF THE TICKET.

(Include all of the identification numbers shown on both sides of the ticket)

MAIL THIS CLAIM FORM, WITH THE TICKET STAPLED ON THE FRONT, TO:

California Lottery, 730 North 10th Street, Sacramento, CA 95811-0336

PRIZE PAYMENT INFORMATION

Claims submitted to Lottery Headquarters for processing are paid by check from the California State Controller's Office. If you do not receive your prize

within eight weeks, contact the Lottery at 1-800-Lottery (568-8379), Monday through Friday, 8:00 a.m. to 5:00 p.m.

A Multiple Ownership Claim Form is available for group players (less than 100) sharing prizes of $1,000,000 or more. You may request a Multiple

Ownership Claim Form by calling 1-800-Lottery (568-8379) or by visiting any Lottery District Office.

PRIVACY NOTICE

The Information Practices Act of 1977 (Cal. Civ. Code sections1798-1798.78, the Federal Privacy Act (Public Law 93-579), 5 U.S.C. section 552a, and Cal.

Gov. Code sections11015.5 and 11019.9, require that this notice be provided when collecting personal information from individuals.

The Player Information requested on this form will be used to validate and process your claim in accordance with the California State Lottery Act of 1984

(Gov. Code sections 8880 et seq.). The Lottery requires a player's social security or tax identification number (SSN/TIN) for tax withholding and reporting

purposes, pursuant to Internal Revenue Code sections 6011, 6041, 6109, 3402, and the regulations enacted thereunder.

The Player Information you provide may be disclosed to various state and federal government agencies, including but not limited to: the State

Controller's Office, Franchise Tax Board, Health and Welfare Agency, and the Internal Revenue Service.

The voluntary information that you provide regarding your ethnicity, household income, education, gender, and occupation will be used only by the

Lottery to conduct internal demographic studies (which may be completed by agents, contractors, and third-party affiliates). It will not be disclosed to

any state or federal government agency or members of the public.

You have the right to access your personal information maintained by the Lottery by contacting the California Lottery, 700 North 10th Street,

Sacramento, CA 95811-0336 - Attention: Information Practices Act Coordinator, Legal Services - Executive Division. The Information Practices

Coordinator can also be reached at 916-822-8177.

Purpose and Relevancy of Information Collected: Information is collected to validate and process a claim and for purposes of sales, marketing, research,

security investigation, legal review, surveys, and strategic planning as related to the operations of the Lottery. By submitting this claim, you consent and

agree to such use, and waive any and all legal claims, known or unknown, related to the specified uses set forth herein. The California Lottery is subject to

public disclosure laws that allow access to certain governmental records. Your full name, the name and location of the retailer who sold you the winning

ticket, the date you won, and the amount of your winnings, including your gross and net installment payments, are matters of public record and are

subject to disclosure. The Lottery will not disclose any other personal or identifying information without your permission unless legally required to do so.

No information will be collected or accepted from known minors. You may be asked to participate in a press conference.

Tickets, transactions, purchases, claims and prize payments are subject to federal and state law and California Lottery regulations, policies and procedures.

Copies of regulations are available at Lottery District Offices and on our website at Tickets failing validation are void.

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CSL 1242 (R03/15)