Fillable Form Wl-108 - The Wisconsin Lottery Winner Claim Form printable pdf download

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The Wisconsin Lottery

Reference Number

Winner Claim Form

INSTRUCTIONS

• Fill out and SIGN the back of your winning ticket in BLACK or BLUE ink.

• Fill out the “Claimant Information” lines 1 thru 15.

Prizes, PO Box 777,

• To receive winnings by mail, send original claim form and ticket(s) in an envelope addressed to

Madison WI 53774 . Make a copy of the claim form and tickets to keep for your records.

• If winnings are $1,000 or more, complete the Driver License or State ID box located at the bottom of the Claimant

Information section.

• Lotto tickets $50,000 or more, or tickets 90 days past the draw date, may take several hours to process. Please call

(608) 261-4916, at least two hours before arrival.

• Please tell us if you plan to cash your check the same day that you claim your winnings. If so, expect a two hour

processing delay at the State’s contracted bank.

Claimant Information –

PLEASE PRINT

Enter last name and tab to continue.

1. Name

2. Birth Date

(Last, First, and M.I.)

(mm-dd-yyyy)

3. Mailing Address

4. County

5. City

6. State

7. Zip Code

8. Country (if NOT United States)

(

)

9. Contact Phone Number

10. Social Security Number

(required if prize amount is $600 or more)

11. Total Prize Amount Claimed

12. Number of

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

Tickets Submitted

Claimant’s Release Authorization

14.

Yes

(If Yes, see back of form)

Pursuant to Wisconsin’s Open Records law (Wis. Stats. Secs. 19.31–19.39),

the Lottery is required to disclose a winner’s name, likeness and place of

residence. If you win and claim a prize, the Lottery may use your name, likeness and place of residence without compensation to

you. Upon claiming your prize, you waive any claims against the Lottery and its representatives for any and all liability which may

result from the disclosure or use of such 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.

Claimant’s Signature

15.

Date

(only one accepted)

Identification for winnings $1,000 or more:

Expiration Date

Driver Lic. #

OR State ID#

Ticket Information –

LOTTERY USE ONLY

Lotto Tickets (for Lottery use – $5,000 or more)

< 90 days

Pass CF Test

16. Instant Ticket Validation Number

(Number on the FRONT of scratch ticket)

> 90 days

Fails CF Test

17. Instant Ticket Number

Lottery Initials

Office

Date Received

(Number on the BACK of scratch ticket)

18. Lotto Ticket Number

WL-108 (R. 12-14)

Wisconsin Department of Revenue

Form Wl-108 - The Wisconsin Lottery Winner Claim Form

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