claim form - Illinois Lottery

CLAIMANT INSTRUCTIONS - IMPORTANT: USE BALL POINT PEN ANDPRESS FIRMLY. YOU ARE MAKING MULTIPLE COPIES.If you believe you or someone you know has a gambling problem, call 1-800-426-2537 (1-800-GAMBLER) for assistance.CLAIMANTCENTER, and email address.3. Mark the appropriate box for individual, group, partnership, corporation or other.6. Mark box indicating whether you are claiming as an individual or on behalf of a group orpartnership. If claiming for a group or partnership complete Form 5754 and attach.7. Print driver’s license number in space provided (other acceptable forms of identification includeSecretary of State issued identification cards, social security cards).8. Sign and date form on claimant’s signature line.SEE ATTACHED ENVELOPE FOR MAILING INSTRUCTIONS. IF MAILING, RETAIN PINK COPY FORYOUR RECORDS AND MAIL WHITE COPY. IF YOU ARE TAKING TO NEAREST CHECK WRITINGCENTER, BE SURE TO BRING SOCIAL SECURITY CARD AND DRIVER’S LICENSE OR SECRETARYOF STATE ID CARD TO CLAIM WINNINGS.CLAIM CENTER INSTRUCTIONSlottery terminal.the six (6) digit retailer number.Sign form on prepared by line.nineteen (19) digit serial number from the lower rightRetain blue copy for your record - return white to Lottery Central and pink copy to claimant.Check writing centers are located at:St.Copy DistributionP.O. Box 19080, Springfield, IL. 62794-9080Checkwriting Center’s copy.Rev. 05/12

CLAIMANT COMPLETE AND PRESENT TO CLAIMS CENTEREmail AddressArea CodeTelephone NumberAre you a non-resident alien? Yes NoWinnings from identical wagers $Prize Amount $I am claiming this prize as the representative of a group or partnership, and have completed and attached a Form5754 identifying each person entitled to any part of this payment and any payments from identical wagers. If I havefurnished a FEIN for a partnership, corporation or other entity, I certify under penalties of Perjury that the numberprovided is correct.TO BE COMPLETED BY CLAIMS CENTERClaimant note: For your immediate redemption of prizesup to $25,000 please visit one of our check writing centersthroughout the state. Valid claims made through the agentand mailed will be paid in approximately 4 weeks. If youdo not receive a response on this claim within one month,contact the Claim Department, Illinois Lottery, P.O. Box19080, Springfield, Illinois 62794-9080. Phone Number1-217-524-1142.IMPORTANT: Validate winning ticket via the lottery terminalDO NOT WRITE IN THIS SPACENote: If you are filing a claim for a Grand Prize for Lotto,Mega Millions, Powerball or a Cash For Life game, pleaseinform the Lottery immediately by calling 1-217-524-5143.STOCK # CHECK # CLAIM #