Example: stock market

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)

Tags:

  Form, Lottery, Claim, Single, Declaration, Prize, Lottery prize claim declaration form

Information

Domain:

Source:

Link to this page:

Please notify us if you found a problem with this document:

Other abuse

Transcription of Lottery Prize Claim Declaration Form (Single)

1 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.

2 10 and 11. This information is intended to be used for the following principal purposes, and for any further purposes reasonably necessary to give effect to these purposes: (1) investigating and validating the Prize Claim ; (2) sharing the information with third parties, including the Alcohol and Gaming Commission of Ontario and police services, for such investigation and validation purposes; (3). monitoring and enforcing compliance with OLG's Lottery Prize Claim Policies and Procedures; (4) publishing the personal information as described in this Declaration form ; (5) assisting OLG in managing its Lottery games and in maintaining the integrity thereof; and (6) complying with legal requirements.

3 Where photocopies of certain identification ( driver's licence) are required to submit to OLG for age and residency verification and/or for identification purposes, this information will be securely destroyed after verification takes place. By submitting this type of identification, you consent to the destruction thereafter. You may visit or speak to a Customer Service Representative for more information on the collection of this information and our Privacy Policy by calling toll-free at 1-800-387-0098. Section A Declaration In consideration of and to induce Ontario Lottery and Gaming Corporation (OLG) to deliver the Prize , as referred to above, to me Select (the undersigned Claimant), I hereby declare that: Yes or No.

4 1. I am the only person having any right, interest or Claim in or to the Ticket referred to above, which has been presented for the Yes No Prize . 2. Do you belong to a group, which purchased or played this Ticket? Yes No 3. I 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. These rules and regulations are available upon request to OLG, and are Yes No also available on the OLG website at 4.

5 I purchased the Ticket from a Lottery retailer. Yes No If yes, name and/or location of Lottery retailer (provide both, if known). If retailer name or location is not known, please explain. If no, please provide the name of the person who purchased the Ticket and an explanation of how you received it. Purchaser name Phone number Explanation Section B Identification of Insider and Related Parties 5. Within 12 months of the date of this Prize Claim , I am or have been: a) a person required to be registered under the Gaming Control Act, 1992.

6 Persons required to be registered ( Registrant ). include (A) Lottery equipment suppliers, Lottery retailer managers, or Lottery retailers, in accordance with Regulation 281/07. Yes No (Lotteries); and (B) operators, sellers, gaming-related suppliers, non-gaming related suppliers, trade unions, category 1. gaming assistants, and category 2 gaming assistants, in accordance with Regulation 78/12 (General). If yes, name of Registrant: b) a director, officer, partner, sole proprietor or employee of a Registrant (as described above), and who is involved in the sale, Yes No redemption, distribution or manufacturing of Lottery products, equipment or services.

7 If yes, name of Registrant: c) a person who is acting on behalf of a Registrant (as described above), and who is involved in the sale, redemption, Yes No distribution or manufacturing of Lottery products, equipment or services. If yes, name of Registrant: Page 1 of 2 LT-PZ025 (02/14). Section B Identification of Insider (continued). d1) a member of OLG's Board of Directors; Yes No a full-time, part-time or student employee of OLG; Yes No a person directly on OLG's payroll; Yes No an Employee of OLG on paid or unpaid leave.

8 Yes No d2) a director, officer or employee of Alcohol and Gaming Commission of Ontario (AGCO) Yes No e) an individual consultant or public sector employee retained by OLG through contracts of retainer for periods of 30. Yes No calendar days or more in the aggregate. f) a director, officer, or employee of: Interprovincial Lottery Corporation (ILC); Yes No a Canadian provincial government Lottery agency or corporation (other than OLG). Yes No g) a member of the Ontario Provincial Police (OPP) assigned to the OPP's AGCO Investigation and Enforcement Bureau.

9 Yes No h) a director, officer, partner, sole proprietor or employee of a supplier to OLG of independent audit, advisory or security Yes No services. If yes, name of supplier: i) an employee of an accountable Ontario Government Ministry of OLG or AGCO: Ministry of Finance; Yes No Ministry of the Attorney General; Yes No j) an immediate family member meaning a married spouse, common-law spouse, child, parent or sibling of a person described in Section B 5a), b), c), d), e), f), g), h) or i) above (whether living in the same residence or not), but excluding Yes No in-laws and step-family members.

10 If yes, provide details of the relationship including the name of the person(s) and their place of work. k) a relative (meaning a person other than an immediate family member) who is connected by blood or marriage and who resides with a person described in Section B 5a), b), c), d), e), f), g), h) or i) above, and includes in-laws and step-family Yes No members. If yes, provide details of the relationship including the name of the person(s) and their place of work. l) an executive ( President, Vice-President) of the union that represents the employees at the retail store where the Ticket Yes No was purchased.


Related search queries