Fillable Winner Claim Form printable pdf download

Winner Claim Form

DR 9168 (08/17/2015)

Colorado Lottery

Instructions to Claimant:

P O Box 7



Please print legibly in black or blue ink.

Pueblo, CO 81002-0007



Complete items 1-11 and sign bottom of form.

1.800.999.2959



Fill out and sign back of ticket.

1. Claimant Type (Check one)



Individual

Partnership

Corporation

Trust

Estate



Individual claiming cash for a group – IRS form 5754 MUST be attached to this claim form. Form 5754 will not be accepted at a later date.

2. Social Security Number or FEIN

*Name and Taxpayer ID# provided must match with IRS.

3. LEGAL Name of Winner and Mailing Address

Name printed here must exactly match name on ticket. Include spaces as needed.

Last

First

Address

Apt # (if any)

City

State

Zip Code

4. Telephone Number

5. Date of Birth (MM-DD-YYYY)

6. Gender



Male



Female

7. Citizenship (Check one)

8. Identification



Type:

Driver’s License

Passport

Other _________



US Citizen – MUST provide Social Security Number in #2 above.



Resident Alien – MUST provide Social Security Number in #2 above.



Non-Resident Alien – please provide country of citizenship: __________

Number

State of Issuance

Lotto: Player has 90 days from date

10. Are you an employee or owner of any business that sells

JACKPOT WINNERS ONLY

of claim to change payment option

Lottery products?

Initial in one of the boxes below:

 Yes

 No

from Annuity to Cash.

If yes: Employer: _____________________________________________

Powerball/Mega Millions: Player has

Address: ____________________________________________________

60 days after becoming entitled to a

prize to elect a payment option.

Cash

Annuity

Undecided

Contact:__________________________ Number:___________________

11. By my signature hereto, I indemnify the Colorado Lottery for any loss which may result if any of the foregoing information is not true and

accurate. I understand that the Colorado Lottery is a state agency and therefore my name, city of residence and prize amount is public record and

may be made available for public information. Under penalty of perjury, I declare that to the best of my knowledge and belief,

(A) the information provided in items 1- 10 above is accurate, and correctly identifies me as the recipient of this payment, and

(CHECK ONE)

(B) I am not a person disqualified by statute or regulation from claiming and/or accepting a prize from the Lottery; and that:



No other person is entitled to any part of these payments;



The information provided on the attached form 5754 correctly identifies each person entitled to any part of this payment.

*SOCIAL SECURITY NUMBER REQUIRED if the amount of any one prize is $600 or more. If you do not provide the Lottery with a tax identification

number and elect not to report your residency status, your prize will be subject to the Internal Revenue Service non-resident withholding

requirements. Colorado and/or Federal Law require the Lottery to check Social Security Numbers for the purpose of enforcing child support,

spousal support, criminal restitution laws, and state debt intercept. (See C.R.S. sections 26-13-118, 26-13-106, 24-35-212(5), 26-13-106(1) and 16-

18.5-106.5, 5 U.S.C. section 552a and 42 U.S.C. sections 405(c)(2)(C)(vi) and 651 et seq.) If you are in arrears, the Lottery is required to withhold the

amount in arrearage or the entire prize, whichever is less.

Claimant’s Signature

Date

---------------------------------------------LOTTERY USE ONLY BELOW THIS LINE ---------------------------------------------

Claim Number

Emp. Initials

TOTAL VALUE OF PRIZE CLAIMED

Warrant Number

Security Initials

Stock Number

Date of Claim

Winning Ticket Type:

 Scratch

 Lotto

 Cash 5

 Powerball

Notes:

Accurint Checked - Initials

 Mega Millions

 Pick 3

 Other ________________

Winner Claim Form

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