Winner Instructions Claim Form Arizona Lottery

ADVERTISEMENT

WINNER INSTRUCTIONS/CLAIM FORM
1. Sign the back of your ticket.
2. Complete and deliver the following form together with the original winning ticket and government-issued ID to the
Arizona Lottery at one of the following locations:
4740 E. University Dr., Phoenix, AZ 85034
2900 E. Broadway Rd., Suite 190, Tucson, AZ 85716
Or mail your ticket, claim form, and a copy of your government-issued ID to the Arizona Lottery at:
P.O. Box 2913, Phoenix, AZ 85062-2913
3. In this form, a “Related Person” is defined as a person ineligible to receive prizes under A.R.S. § 5-567: an officer or
employee of the Lottery; an officer or employee of any person contracting with the Lottery to supply gaming
equipment or Lottery tickets, advertising or consulting services or to draw or otherwise select winning tickets or
shares if the officer or employee is involved in the direct provision of goods or services to the Lottery or has access
to information made confidential by the Lottery; and any spouse, child, sibling, or parent residing as a member of
the same household in the principal place of residence of a person described above.
4. Questions? Contact us at 480-921-4400 or
Last Name
First Name
M.I.
Address
City
State
Zip
Phone (____) ____-_____ SSN _____-____-_____
U.S. CITIZEN/RESIDENT ALIEN
NON-RESIDENT ALIEN
I AM A RETAILER OR EMPLOYEE OF A RETAILER: YES
NO
Prize Amount $
Under penalty of perjury, I certify and declare by my signature below that:
I am at least 21 years of age;
I understand that a person who, with intent to defraud, falsely makes, alters, forges or counterfeits a State Lottery
ticket can be charged with a felony punishable by imprisonment;
I am not a Related Person, as defined above;
I understand that, under A.R.S. § 5-573, my prize information will be reported by my social security number to
Arizona Department of Economic Security, and that my prize may be used to offset child support or State of Arizona
debt owed by me; and
I understand that my taxpayer ID must be provided for tax reporting purposes under 26 U.S.C. § 6109; and I have
provided the correct name, address and taxpayer ID number, as the recipient of this prize.
Claimant’s Signature:
Date

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go