Use this form when claiming a winn ing ticket through the mail or in person at the Lotte ry office.Do not use this form for prizes paid by retailers.

WINNER CLAIM FORM

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4. State -

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ssued by Date //

12.e med

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rson wh with falsely mak alte forges or counterfeits a state lottery ticket is guilty of a clfelony punishab ears in pr

FULL LEGAL NAME ame(s) ame nitial

CONFIDENTIAL

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Revised: 07/2020

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Driver'

Do you have any other ticketsDo you have any other tickets identical to this one for the same game and draw?(see explanation on back)

7. BirthDate

Month Day Year Daytime # Including Area Code

13. Email

If you do not have an email address enter N/A.

14. Winner DeclarationUnder penalty of law, I declare that the name, address, and taxpayer identification number which I have furnished, correctly identify me as the recipient and rightful owner of the prize claimed, and that the ticket attached to this claim has not been falsely made, altered, forged, or counterfeited. I am not the spouse, child, brother, sister, or parent of any member of the Lottery Commission, the Director, the Assistant Directors, or any employee of the Oregon Lottery.

I have read and understand the information on the front and back of this form.

Claimant’s Signature Date

5. Zip

PLEASE PRINT, AND KEEP A COPY FOR YOUR RECORDS AND MAIL

CLAIMING BY MAIL: •

• Keep a copy for your records.

• Mail a copy of the completed form and

• We recommend sending your ticket through registered mail.

PO Box 14515 • Salem, OR 97309

CLAIMING IN PERSON: • may be claimed at:

• may be claimed at:

• Prior to claiming in person, please check

500 Airport Road SE • Salem, OR 97301

9760 SW Wilsonville Rd. • Wilsonville, OR 97070

N/A

WINNER INSTRUCTIONS

• Please use this form for claiming a winningticket through the mail or in person.

• Do not use this form for prizes paid by retailers.

• Download to complete this form electronicallybefore printing.

Item 1

Items - 5 Mailing address.

Item SM

Item

law.For all other Lottery games, the Lottery must report all prizes of or more to the Internal Revenue Service and the Oregon Department of Revenue, and withhold state and federal income

in accordance with state and federal law.

the month/day/year you were born.

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*Disclosure Requirement: Each United States resident who is to receive a payment of winnings greater than $600 shall furnishto the Lottery the info rm rm includingbut not limited to the winner’s name, address, and social security number. is disclosure is mandatory and the authority for such

purpose of identifying child support obligors, identifying persons that have received an overpayment of assistance for which the

INFORMATION ON PRIZE PAYMENT:

If you do not receive your prize or have not been contacted by the Lottery within two weeks, please contactthe Player Services Department at 503-540-1050, Monday through Friday, 8 a.m. to 5 p.m.

PUBLIC INFORMATION

In accordance with Oregon Public Records Law, once a prize has been validated, the following facts are publicinformation and may be subject to public records disclosure:

Winner’s name, city, state and zip codeGame in which prize was wonDate of game drawingDate prize was claimedAmount of prize wonRetail location/city in which winning ticket was sold

CONGRATULATIONS AND THANK YOU FOR PLAYING THE OREGON LOTTERY!

®

Enter email address. If you do not have an email address enter N/A. Your email may be used to contact you regarding the status of your claim and/or for promotional offers from Oregon Lottery. Your email will never be provided to any third parties.

Check yes/no if U.S. Citizen

If more than one ticket for a game (ie: Oregon’s Game MegabucksSM, Powerball®, etc) was purchased for the same drawing (ie: same date and time) and has the same numbers selected, all winnings must be added together for the purpose of tax reporting and withholding requirements. The requirement applies if the total amount of winnings from the identical tickets is greater than $1,500.

WINNER CLAIM FORM INFORMATION