California Lottery Claim Form 2019

You may request a Multiple Ownership Claim Form by calling 1-800-Lottery 568-8379 or by visiting any Lottery District Office. If you do not receive your prize within eight weeks contact the Lottery at 1-800-Lottery 568-8379 Monday through Friday 8 00 a.m. to 5 00 p.m. A Multiple Ownership Claim Form is available for group players less than 100 sharing prizes of 1 000 000 or more. The Player Information requested on this form will be used to validate and process your claim in accordance with the California State Lottery Act of 1984 purposes pursuant to Internal Revenue Code sections 6011 6041 6109 3402 and the regulations enacted thereunder. Include all of the identification numbers shown on both sides of the ticket MAIL THIS CLAIM FORM WITH THE TICKET STAPLED ON THE FRONT TO California Lottery 730 North 10th Street Sacramento CA 95811-0336 PRIZE PAYMENT INFORMATION Claims submitted to Lottery Headquarters for processing are paid by check from the California State Controller s Office. TICKET NUMBER 18-DIGIT NUMBER ON THE FRONT OF TICKET PRIZE CLAIMED I declare under penalty of perjury and the laws of the State of California including but not limited to California Penal Code sections 118 and 72 that I am the rightful owner of the winning ticket on this form that I am 18 years of age or older and that all information provided is true and correct. I understand that any person who with intent to defraud falsely makes alters forges or counterfeits a Lottery ticket is in violation of state law and could be liable for criminal penalties. CONGRATULATIONS Cash all prizes of 599 or less at your participating Lottery Retailer PLAYER INFORMATION SEE PAGE 2 BEFORE COMPLETING FORM LAST NAME DATE OF BIRTH MONTH FIRST NAME MI SUFFIX DAY - SSN/TIN YEAR ADDRESS 1 CITY STATE COUNTRY ZIP CODE E-MAIL PHONE I do not have a Social Security Number I am NOT a U.S. Citizen and I am NOT a Resident Alien Check this box only if you do not have a SSN AREA CODE Are you a Lottery Retailer Yes No Are you employed by a Lottery Retailer Are you related to a Lottery Retailer By volunteering to answer the following questions you will help the Lottery know more about its players. D. CODE DIST. OFFICE CODE DRAW DATE INITIALS FOR HEADQUARTER OFFICE USE ONLY DATE RECEIVED POST MARK DATE CODE S REASON CONTROL NUMBER RELEASED FINAL CRN CSL 1242 R03/15 SEE PAGE 2 FOR MORE INFORMATION Page 1 of 2 PLEASE READ ALL INFORMATION AND INSTRUCTIONS BEFORE COMPLETING CLAIM FORM Failure to provide your original signed winning ticket social security number date of birth name and complete address including apartment or space number city state zip code and phone number may delay or prevent the Lottery from processing your prize claim or result in additional federal taxes withheld from your prize. Your responses will not be sold or disclosed to the public* Which of the following do you consider yourself to be Annual Household Income Education Under 20 000 20 000 to 35 000 Did not finish High School Gender Male African American Check all that apply Asian 35 000 to 50 000 Hispanic Graduated High School or GED Occupation Female White Over 75 000 Other specify Number of People in Household including yourself Some College Student Employed Graduated College Unemployed Retired TICKET INFORMATION Attach winning Scratchers ticket to this form with your name and address showing.