Lottery Prize Claim Declaration Form (Single)

Lottery Prize Claim Declaration form ( single ). For Prizes of $1,000 or more RESET. For Prize Centre purposes only Customer reference number ID type (do not record the ID number). Date of Claim (yyyy/mm/dd). Claimant Information Legal Name (as shown on government issued ID): First name Middle name Last name Home address Street number, street name, unit/apt. number, RR# or PO Box # City Province Postal code Date of birth (yyyy/mm/dd) Home telephone number Mobile number Email address Ticket Information Game name Ticket number Prize amount Notice of Collection of Information The personal information provided on this form is collected under the authority of the Ontario Lottery and Gaming Corporation Act, 1999 and Regulation 198/00, s.

Page 1 of 2. LT-PZ025 (02/14) Lottery Prize Claim Declaration Form (Single) For Prizes of $1,000 or more. For Prize Centre purposes only Customer reference number ID type (do not record the ID number)

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