Lottery Prize Claim Form printable pdf download

ATLANTIC LOTTERY CORPORATION INC. (ALC) - PRIZE CLAIM FORM

PRIZE CLAIMANT INFORMATION:

Scotia Bank Transit #

yes □ no □

Is this a group win?

If yes, please fill out a Group Win Agreement.

 Mr.  Mrs.  Miss  Ms

Today’s Date:_______________________ Date of Birth: (DDMMMYYY)________________________

Name(s) (

)____________________________________________________________________________

please print

Address: ____________________________________________________________________________________

City/Town: __________________________________ Prov: __________

Tel: (_____)_________________

Postal Code:______________________

Email: _____________________________________ Gender: M or F

Prize Claim under previous name (ex. maiden name): _________________________________________________

Primary Identification with picture: Type: _____________________

If no primary identification available, 2 secondary identification will be required: Type:____________________ Type:_____________________

(a photocopy of front and back of ID to be attached)

TICKET INFORMATION: (Please attach original)

Game/Ticket Name:__________________________________Prize Amount:___________________________________ Draw Date: ________________

STATUTORY DECLARATION

In consideration of and to induce ALC to deliver the Prize, as referred to above, to the undersigned (the “Claimant(s)”), the Claimant(s) hereby declares and represents that:

the Prize Claimant(s) and Ticket Information above, and the information contained in the Disclosure Statement is true, accurate and complete and forms part of this

Agreement;

the Claimant(s) is the holder of the Ticket referred to above, came into possession of the Ticket in a lawful and legitimate manner and in accordance with the Rules and

Regulations governing the purchase and issuance of the Ticket, and was lawfully entitled to possession of the Ticket at the time it was presented for the Prize:

the Claimant(s) truthfully, accurately and completely responded to/answered all requests for information made by ALC related to the Ticket and reasonably required for

ALC to process the claim for the Prize in accordance with ALC’s policies and the Rules and Regulations governing the payment of the Prize;

no other person(s) has any right, interest or claim in or to the Ticket;

DISCLOSURE STATEMENT:

At any point during the period of time between: (i) the purchase of the Ticket referred to above, and (ii) the prize claim based on this Ticket, have you as a Prize Claimant

listed above been:

If yes, provide:

An employee or Board Member of ALC, the Interprovincial

□

Employer name and your title/position:

Lottery Corporation, or Nova Scotia Gaming Corporation or a

□

yes

lottery regulator in NB, PEI or NFLD.

An ALC lottery ticket retailer or a person with a business or

□

Retailer name and location and your interest in retailer:

ownership interest in an ALC lottery ticket retailer

□

yes

An employee of an ALC lottery ticket retailer where you were

□

Retailer name and location, your title/position and your

involved in, or where you supervised or managed a person(s)

involvement with ALC lottery tickets:

□

yes

involved in, the handling, sale and/or validation of lottery tickets

An ALC supplier of lottery ticket related goods or services or an

□

Supplier name and your title/position with supplier:

employee or a person with any type of business interest in such

□

yes

a supplier

A spouse (including common law), fiancée, sibling, parent or

□

Name of the person(s) referred to in 1-4 above, name of

child of any of those referred to in 1-4 above

his/her employer(s), which category (1-4) that person falls in

□

yes

and your relationship with that person:

A person that resides, or resided with any of those referred to in

Name of the person(s) referred to in 1-4 above, name of his/

□

lines 1-4 above

her employer(s) and which category (1-4) that person falls in:

□

yes

I acknowledge and agree that should any statement above not be true, accurate or complete, this matter may be reported to law enforcement and will result in any prize to

which I may be entitled being withheld for a minimum period of 60 days to allow for a full investigation.

I DECLARE that the statements above are true, accurate and complete and I make this solemn declaration conscientiously believing it to be true, and knowing that it is of the

same force and effect as if made under oath.

DECLARED before me at the city/town of ____________________________________

) _____________________________________________________

) Print Claimant’s Name

Province of __________________ , this ____ day of __________________, 20_______

__________________________________________

) _____________________________________________________

) Claimant’s Signature

A Commissioner of Oaths

RELEASE, INDEMNITY AND CONSENT

In consideration of and to induce ALC to deliver the Prize, as referred to above, to the undersigned (the “Claimant(s)”), the Claimant(s) hereby agrees that:

upon delivery of the Prize to the Claimant(s) by ALC, the Claimant(s) hereby releases and discharges ALC, its employees, officers, directors and shareholders, from any

further claims, actions or demands by the Claimant(s) in respect of the Ticket and any further prize claims, including in relation to unclaimed prizes, in respect of the Ticket;

the Claimant(s) will indemnify and save the ALC harmless from and against any and all actions, claims, demands or costs (including costs incurred by ALC in defending

against such actions, claims or demands) of any nature whatsoever brought against ALC or arising with respect to the Ticket or the delivery of the Prize;

the Claimant(s) hereby gives ALC the right to publish, through all types of media broadcasting, including the internet, for the purposes of promoting the win, the

Claimant's name, hometown and photograph without any claim for broadcasting, printing or other rights for a period of up to twelve months from the date of prize award, as

outlined in ALC’s Winners Information Publicity Policy. The Claimant also gives ALC the right to publish for a period of up to twelve months from the date of the prize

award any additional information that the Claimant(s) voluntarily provides. The Claimant(s) shall have no claim against ALC for invasion of privacy or any other ground(s)

by reason of the publication or broadcasting of the Claimant's name, hometown or photograph or information voluntarily provided by the Claimant(s).

the Claimant(s) consents to ALC using information collected by or on behalf of ALC for the purposes of processing, administering and paying the Prize, in accordance

with the Rules and Regulations governing payment of prizes, as well as conditions governing Related (Non-Arms Length) Parties prize claims, all in accordance with ALC

Privacy Policies. The Claimant(s) consents to ALC using the contact information above for the purpose of follow-up research with respect to the prize claim process and

winning experience. The Claimants(s) consents to ALC using Prize Claimant(s) information above to search for outstanding support orders against the Prize Claimants(s);

this agreement shall be binding upon the heirs, executors, administrators and assigns of the Claimant(s) and shall enure to the benefit of ALC and its successors, assigns,

affiliates, officers, directors, employees and agents.

IN WITNESS WHEREOF, the Claimant has hereto set the Claimant's hand(s) and seal(s) at the City of

, in the Province of _________________,

on the ______ day of ________________, 20_____

SIGNED SEALED AND DELIVERED in the presence of:

_____________________________________________________

Claimant’s Signature

_________________________________

V201504

Witness