Winner Claim Form
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1FOR LOTTERY USE ONLY
WINNER CLAIM FORM
DATE
MAIL TO:
CASHIER’S INITIALS
HOOSIER LOTTERY
CHECK NO.
1302 N. MERIDIAN ST.
CLAIM NO.
INDIANAPOLIS, IN 46202
1-800-955-6886
RETAILER NO.
INSTRUCTIONS TO CLAIMANT:
• YOU MUST SIGN YOUR NAME ON THE BACK OF TICKET.
STAPLE TICKET
• ON BACK OF TICKET, PRINT YOUR NAME & ADDRESS.
TO TOP COPY
• COMPLETE ITEMS 7 THROUGH 19 BELOW (PLEASE PRINT).
HERE
• YOU MUST SIGN YOUR NAME ON THE CLAIM FORM.
• STAPLE TICKET TO THE FRONT OF THE CLAIM FORM.
• MAIL THE CLAIM FORM TO THE ABOVE ADDRESS.
PLEASE DO NOT STAPLE THROUGH
• KEEP A COPY OF CLAIM FORM AND TICKET FOR YOUR RECORDS.
• PROVIDE A COPY OF A GOVERNMENT ISSUED PICTURE I.D.
ANY NUMBERS OR PLAY SPOTS ON TICKET!
For your protection, we suggest you mail your claim by certified mail.
CIRCLE ONE: DRAW GAME
OR
INSTANT GAME
1.TICKET
2. DRAW
NO.
DATE
(MM-DD-YY)
4. GAME TYPE
3. VALIDATION NO.
.00
.00
6. WAGER AMOUNT
5. PRIZE AMOUNT
7. NAME
LAST NAME - PLEASE PRINT
FIRST NAME
MI
8. ADDRESS
9. CITY
10. STATE
11. ZIP CODE
13. NATION
12. COUNTY NAME
15. DATE OF
16. US
14. SOCIAL
BIRTH
CITIZEN
YES
NO
SECURITY NO.
(MM-DD-YY)
The Hoosier Lottery is required by federal law to obtain the prize winner’s social security number for all prizes $600 or greater in order to report taxes
and to comply with IC 4-30-11-11. Winner claim forms cannot be processed without this information.
17. PHONE NUMBER
18. This prize is claimed as follows:
A
for myself as the sole winner
B
as a member of the winning group designated on the attached IRS Form 5754
C
on behalf of the person(s) designated on the attached IRS Form 5754
The Hoosier Lottery will withhold Federal and State taxes at the minimum amount required by IRS regulations and Indiana
19.
State Law. It is important to understand that the taxes withheld may not cover all of your Federal or State tax obligations.
The final tax amount owed will depend on your personal tax situation. As the Hoosier Lottery or its employees cannot provide
you with financial advice, we suggest you talk with a professional tax advisor.
Initial
here
The Hoosier Lottery may require that you participate in press conferences and other public relations activities.
Under penalty of perjury, I hereby declare that, to the best of my knowledge and belief, the name, address, and social security
number provided correctly identify the recipient(s) of the payment of the validated winning ticket and that the purchaser of the ticket
is not prohibited by law from purchasing a lottery ticket.
I understand that any person who, with intent to defraud, falsely presents for payment a forged, counterfeit or altered ticket is in
violation of state law and may be prosecuted. I further acknowledge that I have read and understand the information listed above
concerning tax withholdings on my lottery winnings received today.
CLAIMANT'S SIGNATURE_________________________________________
DATE___________________
Form J-06
Version 3/13
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