Winners Claim Form - Wisconsin Lottery

Winner Claim Form The Wisconsin Lottery
www.wilottery.com
INSTRUCTIONS
• Fill out and sign the back of your winning ticket in blue or black ink.
• Fill out the “Claimant Information” blocks as they apply to you and your winnings.
• Sign Line 17. Read the information on the back of this form.
• To receive winnings by mail, please complete and send along with ticket(s) to: Prize Payments,
Madison WI 53774. Keep a copy of your ticket and the pink copy of this form for your records
and reference.
NOTE: The Wisconsin Lottery only makes payment on the original ticket.
• On-line tickets $5,000 or more may take several hours to process and it is recommended that
you call in advance and arrive no later than 2 p.m. on the day you claim your prize. You may
call (608) 267-2839 for further information.
• You must notify validation staff if you plan to cash your check today (see back of this form).
There is a 2 hour delay for same day cashing of lottery checks.
£ TICKET INFORMATION
TICKET(S) $600 OR GREATER
1. Instant Ticket Validation Number 2. Instant Ticket Number
(15-digit number on the FRONT of scratch ticket) (13-digit number on the BACK of scratch ticket)
3. On-Line Ticket Number
TICKET(S) LESS THAN $600
4. Number of Tickets Submitted
VALIDATION OFFICE USE ONLY
ALL TICKETS
5. Total Prize Amount Claimed 6. Is prize being claimed by more than one person?
,
,
.
$ 0 0
No Yes £ If so, see back of form.
£ CLAIMANT INFORMATION
Reference Number
7. Last Name, First Name, M.I. 8. Birth Date
Please staple winning
instant or on-line ticket(s)
to the top copy of this
form. Do not use glue or
tape. Please do not staple
through winning numbers
or play spots on ticket.
On-Line Tickets
(for Lottery use –
$5,000 or more)
< 90 days
> 90 days
Pass CF Test
Fails CF Test
Month Day Year
9. Street Address 10. County
11. City 12. Country (if not United States)
13. State 14. Zip Code 14a. Daytime Phone Number (include area code) 14b. Alternate Phone Number (include area code)
15. Social Security Number
16. Winner’s Release Authorization
Consistent with State of Wisconsin Open Records law, s. 19.31 to 19.39, Stats., the Lottery may use your name, likeness and/or
town of residence, without compensation to you, in public information efforts. Upon claiming your prize, you are releasing the
Wisconsin Lottery and its representatives from any and all liability which may result from the use or release of the information.
I have read the instructions for this form and understand my rights and responsibilities as a Lottery winner. I hereby certify that I am
18 years of age or older and that all information provided is true and correct. I understand that any person who, with intent to defraud,
falsely makes, alters, forges, or counterfeits a state lottery ticket is in violation of state criminal law. If I choose not to provide
my social security number, my winnings will be taxed at a higher rate, which may affect the amount or timing of any prize paid.
17. Winner’s Signature (only one will be accepted) Date
Game
Number
Winner Initials
(Receipt of check)
Lottery Initials
(Received by)
Office Date Received
Winnings $1,000 or more Identification:
Driver Lic. # Exp.
Claimant Photo? Yes No
Wisconsin Department of Revenue

Mandatory Information (must be provided to receive your check)
You must provide your name, birth date, address, city, state, and
zip code. We ask that you also provide your social security
number to facilitate the payment of your prize (items 7, 8, 9, 11,
13, 14, 15). Sign this form (item 17) and the back of your instant
or on-line ticket.
Note: Item 15 Wisconsin Statutes 565.30(5t) require the Lottery
to check social security numbers with the Department of Revenue
for claimants of all prizes of $1,000 or more. If your prize is $1,000
or more, and you do not, or cannot, provide your social security
number, you will not receive your check at this time, until after
we have researched the Department of Revenue delinquency
files.
In addition, federal back-up withholding will be deducted from
all prizes $600 or greater if your social security number is not
NOTES:
Item 6 Multiple-Owned Tickets. To share a Lottery prize
ALL of the following must be completed:
• The Lottery will recognize more than one claimant
claiming a prize from a single ticket only when item 6
on the front of this form is answered “yes” and each
claimant in the group completes a claim form.
• A court order is required for any prize for which there
is more than one claimant. The court order must be
accompanied by a separate winner claim form for
each prize claimant.
• Multiple-owned tickets must be processed at the
Madison office. This process may take up to two
weeks after the court order is received.
• A person claiming a prize or part of a prize is subject
to withholding, pursuant to Wis. Stats. 565.30(5t),
the amount to be withheld shall be deducted from
the prize claimant’s proportionate share of the total
prize.
• For tax reporting purposes, the Lottery will recognize
only those individuals who have filed a claim form
for a particular prize. Once a prize has been paid,
the Lottery will not accept requests to add persons
to the list of individuals who will share a prize.
• On-line tickets $5,000 or more may take several hours to
process. Please call the office ahead of your arrival time.
You must arrive by 2:00 p.m. to assure payment that day.
• If you are CASHING YOUR CHECK TODAY, you must alert
validation staff when you receive your check, and they will
notify the bank. There is a 2 hour delay for same day cashing
of Lottery checks.
Instructions
provided. Without a social security number, only checks $600 to
$999 will be received on the day processed and will have federal
back-up withholding deducted from the gross amount of the prize
paid.
All other information requested on this form is voluntary. If you
have any questions regarding the validation of your winning ticket,
please call the Lottery Validations Office at (608) 267-2839.
Note: Tickets are void if stolen, unissued, mutilated, altered,
unreadable, counterfeit, misregistered, defective, mis-printed or
otherwise fail validation tests.
All tickets submitted to the Wisconsin Lottery become property
of the Lottery and will not be returned.
All tickets are subject to the Features and Procedures of the
given game. Features and Procedures for individual games are
available upon request.
Item 7 Enter only one person’s name for item. Multiple-owned
tickets must be processed at the Madison office (see
Item 6).
Item 15 Disclosure of Social Security Number. Your social
security number will be used to report the amount of
your winnings to the Internal Revenue Service, as
required under Federal law. Your prize winnings are
subject to both federal and state income tax withholding.
Federal taxes (at the current rate) are automatically
deducted from prize payments of $5,001 or more. State
taxes (at the current rate) are automatically deducted
from prize payments of $2,000 or more. This may not
be your entire tax liability. Please consult your tax
advisor for further assistance. Withholding rates are
subject to change. (See mandatory information
regarding not providing a social security number.)
Item 16 Winner’s release authorization. Consistent with
State of Wisconsin Open Records law, s. 19.31 to
19.39, Stats., the Lottery may use your name, likeness
and/or town of residence, in public information efforts
without compensation to you. Upon claiming your prize,
you release the Wisconsin Lottery and its representatives
from any and all liability which may result from
the use or release of the information.
• You may call (608) 267-2839 for further information.
• Jackpot Prizes resulting in annuity or cash option choices
must be claimed at the Madison office. Please contact Lottery
Player Relations at (608) 261-4916 prior to claiming your ticket.