LOTTERY PRIZE CLAIM GROUP LIST - Home Page | OLG

1 LOTTERY PRIZE CLAIM GROUP LISTTo CLAIM a LOTTERY PRIZE purchased by a GROUP of two (2) or more individuals (each a GROUP Member and collectively, GROUP Members ), the GROUP Members must complete and submit this LOTTERY PRIZE CLAIM GROUP list ( List ) in addition to each GROUP Member completing and submitting the LOTTERY PRIZE CLAIM Declaration Form to the Ontario LOTTERY and Gaming Corporation ( OLG ). The List must be signed by all GROUP GROUP Member agrees and declares as follows: 1. The GROUP Members are the joint owners of the LOTTERY ticket described below in the proportions stated below.

2 2. If OLG determines that the LOTTERY ticket qualifies as a winning ticket, and payment of the LOTTERY PRIZE can be made pursuant to the applicable rules and regulations of OLG and/or of the Interprovincial LOTTERY Corporation ( ILC ), including in accordance with OLG's LOTTERY PRIZE CLAIM Policies and Procedures, then the List constitutes OLG's, or the ILC's if applicable, sufficient authority and instruction to make individual payments to each GROUP Member whose name appears on the List in the proportions stated below.

3 3. In case of death of a GROUP Member, the GROUP Member's respective rights in the LOTTERY ticket will pass to his or her estate; this List is binding upon his or her heirs, executors and Each GROUP Member releases, indemnifies and saves harmless OLG from any CLAIM with respect to distribution of PRIZE monies to GROUP Members in accordance with the information contained in this List. 5. This List is made available by OLG solely for convenience of the GROUP Members with respect to the distribution of PRIZE monies.

4 OLG assumes no responsibility for: a GROUP Member's entitlement to any PRIZE , compliance with any laws that may prohibit or restrict groups playing lotteries, or for the accuracy of any of the information contained on the List. Effective Date of List:Date of LOTTERY PRIZE CLAIM :Number of GROUP Members:Name of GROUP Leader: LOTTERY Ticket InformationName of LOTTERY Game:Date of Draw or Sports Event:Ticket Number: GROUP Members#Print Legal Name (first and last)Address (street, city, PO Box)Postal CodeTelephone (day)Proportion of PRIZE (must total 100%)Signature12345678910LT-PZ027 (04/15)The personal information provided on this List is collected under the authority of the Ontario LOTTERY and Gaming Corporation Act, 1999 and Regulation 198/00, s.

5 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) complying with legal and audit requirements; (2) investigating and validating the PRIZE CLAIM ; (3) sharing the information with third parties, including the Alcohol and Gaming Commission of Ontario and police services, for such investigation and validation purposes; (4) monitoring and enforcing compliance with OLG's LOTTERY PRIZE CLAIM Policies and Procedures; (5) assisting OLG in managing its LOTTERY games and in maintaining the integrity thereof; and (6) awarding prizes.

6 Where photocopies of certain identification ( driver's licence) are required to be submitted 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 Members (continued)#Print Legal Name (first and last)Address (street, city, PO Box)Postal CodeTelephone (day)Proportion of PRIZE (must total 100%)

7 Signature1112131415161718192021222324252 627282930 The personal information provided on this List is collected under the authority of the Ontario LOTTERY and Gaming Corporation Act, 1999 and Regulation 198/00, s. 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) complying with legal and audit requirements; (2) investigating and validating the PRIZE CLAIM ; (3) sharing the information with third parties, including the Alcohol and Gaming Commission of Ontario and police services, for such investigation and validation purposes.

8 (4) monitoring and enforcing compliance with OLG's LOTTERY PRIZE CLAIM Policies and Procedures; (5) assisting OLG in managing its LOTTERY games and in maintaining the integrity thereof; and (6) awarding prizes. Where photocopies of certain identification ( driver's licence) are required to be submitted 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.

9 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 (04/15)