Transcription of CALIFORNIA LOTTERY 2nd CHANCE WINNER CLAIM
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CALIFORNIA LOTTERY 2nd CHANCE WINNER CLAIM
CALIFORNIA LOTTERY2nd CHANCE WINNER CLAIM PLAYER INFORMATIONCSL 1358 (R09/17)LAST name :SUFFIX:FIRST :ADDRESS 1:ADDRESS 2: city :STATE:ZIP CODE:EMAIL:BIRTH DATE: //SOCIAL SECURITY NUMBER:--Social Security NumberI do not have aI am Not a citizen, and I am Not a resident alienDAYTIME PHONE NUMBER: ()YesNoAre you a LOTTERY retailer?YesNoAre you employed by a LOTTERY retailer?YesNoAre you related to a LOTTERY retailer?PRIZE INFORMATIONPRIZE name :DRAWING name :TICKET ID/ ENTRY CODE:DRAWING ID (IF APPLICABLE):PROVIDING THE FOLLOWING INFORMATION IS VOLUNTARYW hich of the following do you consider yourself to be:Annual household income (Check one)African AmericanHispanicWhiteAsianOther (specify)Under $20,000$35,000 to $50,000$50,000 to $75,000$20,000 to $35,000 Over $75,000 Number of people in householdEducation (Check one)Did not finish high schoolHigh School Graduate or GEDSome collegeGraduated CollegeGender (Check one)FemaleMaleOccupation (Check all that apply)StudentEmployedUnemploy
Page 2 of 2. CALIFORNIA LOTTERY. 2nd CHANCE WINNER CLAIM . PLEASE READ ALL INFORMATION AND INSTRUCTIONS BEFORE RETURNING THIS CLAIM FORM. Failure to provide your social security number, date of birth, name, and complete address (including apartment or space number), city, state, zip
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