Winner Claim Form - 2009

WINNER IDENTIFICATION:

STAPLE TICKET TO THIS CORNER

AMOUNT VALIDATED AND VERIFIED:

SEC. INITIALS:

DATE/TIME:

$

RETAILER #:

CLAIM #:

CHECK #:

CLAIM CENTER REP:

DATE/TIME:

OTHER:

INSTRUCTIONS TO CLAIMANT

1.

1.

On back of ticket, print your name, address and telephone number and sign your name.

On back of ticket, print your name, address and telephone number and sign your name.

2.

On this form, complete items 1 through 14, read and sign item 15. The signature on this claim form must match the signature on the back of ticket. Entire form must be completed for payment.

2.

On this form, complete items 1 through 14, read and sign item 15. The signature on this claim form must match the signature on the back of ticket. Entire form must be completed for payment.

Attach signed ticket and mail top (white) copy of this form to: New Mexico Lottery Claim Center, PO Box 93190, Albuquerque, NM 87199-3190. Or present at the

3.

3.

Make a copy of this form for your records. Attach signed ticket to the original form and mail to: New Mexico Lottery, Attn: Claim Center, PO Box 93190, Albuquerque, NM 87199-3190.

Lottery Claim Center located at 4511 Osuna Rd. NE in Albuquerque.

Or present at the Lottery Claim Center located at 4511 Osuna Rd. NE in Albuquerque. For questions and office hours call: 505-342-7600 or 1-800-642-6689.

4.

Keep the bottom (yellow) copy of this form for your records. For questions and office hours call: 505-342-7600 or 1-800-642-6689.

1. SCRATCHER TICKET NUMBER

(Use 12 digit number on back of the ticket above the bar code.)

Game

Pack

Ticket

DRAWING GAME TICKET NUMBER

OR

(Use 35 digit number on the front of the ticket above the bar code.)

2. PRIZE AMOUNT CLAIMED

3. NAME

,

,

$

.

Last

First

M.I.

4. MAILING ADDRESS

7. COUNTRY

8. DAYTIME PHONE NUMBER

9. SOCIAL SECURITY NUMBER

6. STATE / ZIP CODE

11. EMPLOYER

13. SEX

14. DATE OF BIRTH

12. CITIZENSHIP/RESIDENCY

(for tax purposes - check only one box)

MALE

U.S. CITIZEN

NON-RESIDENT ALIEN

FEMALE

RESIDENT ALIEN

15. SIGNATURE

I acknowledge that certain information in this form, such as my name, city in which I live and the prize amount won, is subject to disclosure pursuant to the New Mexico Inspection of Public

Records Act (NMSA 1978, Chapter 14, Article 2). I understand that the New Mexico Lottery Authority and its retailers and advertising agencies as well as the news media and their editors

may use my name and photograph for reproduction in any medium they see fit for the purposes of advertising, display, exhibition or editorial use. Under penalty of law, I declare that the

name, address and taxpayer identifying number, which I have furnished, correctly identify me as the recipient of the prize claimed and that I have purchased or obtained this ticket legally. I

understand that it is unlawful to make, alter, forge, pass, present or counterfeit, with intent to defraud, a lottery ticket, or receipt for the purchase thereof, issued or purported to have been

issued by the Lottery under the New Mexico Lottery Act. By signing below, I acknowledge the aforementioned laws and requirements and affirm that I am 18 years of age or older.

White Copy - Lottery

CLAIMANT'S SIGNATURE X

DATE

Yellow Copy - Winner

Revised 7/09 0907FRMCLM-2

Revised 7/09 0907FRMCLM