LT-PZ024 Release of Prize Claim - OLG

1 LT-PZ024 (08/15) Release of Prize ClaimFor Prize Centre purposes onlyCustomer reference numberID type (do not record the ID number)Date of Claim (yyyy/mm/dd)Legal Name of ReleasorLegal name (as shown on government issued ID):First nameMiddle nameLast nameHome address - Street number, street name, unit/apt. number, RR# or PO Box #CityProvincePostal codeHome telephone numberDate of birth (yyyy/mm/dd)Email addressLegal Name of ClaimantLegal name (as shown on government issued ID):First nameMiddle nameLast nameTicket InformationGame nameTicket numberName and/or location of retailer where ticket was purchasedFor good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I (the undersigned Releasor): 1. Represent to Ontario Lottery and Gaming Corporation (OLG) and (where applicable Interprovincial Lottery Corporation (ILC)), that I have no, and am not claiming any, right or interest in the Ticket or entitlement to the Prize , and I hereby renounce all right, interest and entitlement that I may have previously claimed in the Ticket and the Prize .

2 2. Release and forever discharge OLG and ILC, and their respective employees, officers, directors, and shareholders (collectively referred to as the "Releasees"), from all claims, demands, damages, actions or causes of action arising or to arise by reason of the Ticket or the payment or the awarding of the Prize to another person or persons, and from all claims or demands whatever in law or in equity which I, my heirs, executors, administrators or assigns can, shall or may have against the Releasees. 3. Agree not to make any Claim , or to commence or maintain any action or proceeding, against any person or corporation, in which any Claim could arise against the Releasees for contribution or indemnity. IN WITNESS WHEREOF, I have signed this document at the town/city of ,in the province of, on theday of, in the presence of:Witness name (cannot be claimant)Releasor nameWitness signature Releasor signature))))A photocopy of valid government issued identification with the date of birth must be submitted with the signed form.

3 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. 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) assisting OLG in managing its lottery games and in maintaining the integrity thereof; and (5) complying with legal requirements. 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.

4 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 of Collection InformationFor Prize Centre purposes only: Comments.