Winners Claim Form - Wisconsin Lottery
Winners Claim Form - Wisconsin Lottery
Winners Claim Form - Wisconsin Lottery
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Winner <strong>Claim</strong> <strong>Form</strong> The <strong>Wisconsin</strong> <strong>Lottery</strong><br />
www.wilottery.com<br />
INSTRUCTIONS<br />
• Fill out and sign the back of your winning ticket in blue or black ink.<br />
• Fill out the “<strong>Claim</strong>ant Information” blocks as they apply to you and your winnings.<br />
• Sign Line 17. Read the information on the back of this form.<br />
• To receive winnings by mail, please complete and send along with ticket(s) to: Prize Payments,<br />
Madison WI 53774. Keep a copy of your ticket and the pink copy of this form for your records<br />
and reference.<br />
NOTE: The <strong>Wisconsin</strong> <strong>Lottery</strong> only makes payment on the original ticket.<br />
• On-line tickets $5,000 or more may take several hours to process and it is recommended that<br />
you call in advance and arrive no later than 2 p.m. on the day you claim your prize. You may<br />
call (608) 267-2839 for further information.<br />
• You must notify validation staff if you plan to cash your check today (see back of this form).<br />
There is a 2 hour delay for same day cashing of lottery checks.<br />
£ TICKET INFORMATION<br />
TICKET(S) $600 OR GREATER<br />
1. Instant Ticket Validation Number 2. Instant Ticket Number<br />
(15-digit number on the FRONT of scratch ticket) (13-digit number on the BACK of scratch ticket)<br />
3. On-Line Ticket Number<br />
TICKET(S) LESS THAN $600<br />
4. Number of Tickets Submitted<br />
VALIDATION OFFICE USE ONLY<br />
ALL TICKETS<br />
5. Total Prize Amount <strong>Claim</strong>ed 6. Is prize being claimed by more than one person?<br />
,<br />
,<br />
.<br />
$ 0 0<br />
No Yes £ If so, see back of form.<br />
£ CLAIMANT INFORMATION<br />
Reference Number<br />
7. Last Name, First Name, M.I. 8. Birth Date<br />
Please staple winning<br />
instant or on-line ticket(s)<br />
to the top copy of this<br />
form. Do not use glue or<br />
tape. Please do not staple<br />
through winning numbers<br />
or play spots on ticket.<br />
On-Line Tickets<br />
(for <strong>Lottery</strong> use –<br />
$5,000 or more)<br />
< 90 days<br />
> 90 days<br />
Pass CF Test<br />
Fails CF Test<br />
Month Day Year<br />
9. Street Address 10. County<br />
11. City 12. Country (if not United States)<br />
13. State 14. Zip Code 14a. Daytime Phone Number (include area code) 14b. Alternate Phone Number (include area code)<br />
15. Social Security Number<br />
16. Winner’s Release Authorization<br />
Consistent with State of <strong>Wisconsin</strong> Open Records law, s. 19.31 to 19.39, Stats., the <strong>Lottery</strong> may use your name, likeness and/or<br />
town of residence, without compensation to you, in public information efforts. Upon claiming your prize, you are releasing the<br />
<strong>Wisconsin</strong> <strong>Lottery</strong> and its representatives from any and all liability which may result from the use or release of the information.<br />
I have read the instructions for this form and understand my rights and responsibilities as a <strong>Lottery</strong> winner. I hereby certify that I am<br />
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,<br />
falsely makes, alters, forges, or counterfeits a state lottery ticket is in violation of state criminal law. If I choose not to provide<br />
my social security number, my winnings will be taxed at a higher rate, which may affect the amount or timing of any prize paid.<br />
17. Winner’s Signature (only one will be accepted) Date<br />
Game<br />
Number<br />
Winner Initials<br />
(Receipt of check)<br />
<strong>Lottery</strong> Initials<br />
(Received by)<br />
Office Date Received<br />
Winnings $1,000 or more Identification:<br />
Driver Lic. # Exp.<br />
<strong>Claim</strong>ant Photo? Yes No<br />
<strong>Wisconsin</strong> Department of Revenue
Mandatory Information (must be provided to receive your check)<br />
You must provide your name, birth date, address, city, state, and<br />
zip code. We ask that you also provide your social security<br />
number to facilitate the payment of your prize (items 7, 8, 9, 11,<br />
13, 14, 15). Sign this form (item 17) and the back of your instant<br />
or on-line ticket.<br />
Note: Item 15 <strong>Wisconsin</strong> Statutes 565.30(5t) require the <strong>Lottery</strong><br />
to check social security numbers with the Department of Revenue<br />
for claimants of all prizes of $1,000 or more. If your prize is $1,000<br />
or more, and you do not, or cannot, provide your social security<br />
number, you will not receive your check at this time, until after<br />
we have researched the Department of Revenue delinquency<br />
files.<br />
In addition, federal back-up withholding will be deducted from<br />
all prizes $600 or greater if your social security number is not<br />
NOTES:<br />
Item 6 Multiple-Owned Tickets. To share a <strong>Lottery</strong> prize<br />
ALL of the following must be completed:<br />
• The <strong>Lottery</strong> will recognize more than one claimant<br />
claiming a prize from a single ticket only when item 6<br />
on the front of this form is answered “yes” and each<br />
claimant in the group completes a claim form.<br />
• A court order is required for any prize for which there<br />
is more than one claimant. The court order must be<br />
accompanied by a separate winner claim form for<br />
each prize claimant.<br />
• Multiple-owned tickets must be processed at the<br />
Madison office. This process may take up to two<br />
weeks after the court order is received.<br />
• A person claiming a prize or part of a prize is subject<br />
to withholding, pursuant to Wis. Stats. 565.30(5t),<br />
the amount to be withheld shall be deducted from<br />
the prize claimant’s proportionate share of the total<br />
prize.<br />
• For tax reporting purposes, the <strong>Lottery</strong> will recognize<br />
only those individuals who have filed a claim form<br />
for a particular prize. Once a prize has been paid,<br />
the <strong>Lottery</strong> will not accept requests to add persons<br />
to the list of individuals who will share a prize.<br />
• On-line tickets $5,000 or more may take several hours to<br />
process. Please call the office ahead of your arrival time.<br />
You must arrive by 2:00 p.m. to assure payment that day.<br />
• If you are CASHING YOUR CHECK TODAY, you must alert<br />
validation staff when you receive your check, and they will<br />
notify the bank. There is a 2 hour delay for same day cashing<br />
of <strong>Lottery</strong> checks.<br />
Instructions<br />
provided. Without a social security number, only checks $600 to<br />
$999 will be received on the day processed and will have federal<br />
back-up withholding deducted from the gross amount of the prize<br />
paid.<br />
All other information requested on this form is voluntary. If you<br />
have any questions regarding the validation of your winning ticket,<br />
please call the <strong>Lottery</strong> Validations Office at (608) 267-2839.<br />
Note: Tickets are void if stolen, unissued, mutilated, altered,<br />
unreadable, counterfeit, misregistered, defective, mis-printed or<br />
otherwise fail validation tests.<br />
All tickets submitted to the <strong>Wisconsin</strong> <strong>Lottery</strong> become property<br />
of the <strong>Lottery</strong> and will not be returned.<br />
All tickets are subject to the Features and Procedures of the<br />
given game. Features and Procedures for individual games are<br />
available upon request.<br />
Item 7 Enter only one person’s name for item. Multiple-owned<br />
tickets must be processed at the Madison office (see<br />
Item 6).<br />
Item 15 Disclosure of Social Security Number. Your social<br />
security number will be used to report the amount of<br />
your winnings to the Internal Revenue Service, as<br />
required under Federal law. Your prize winnings are<br />
subject to both federal and state income tax withholding.<br />
Federal taxes (at the current rate) are automatically<br />
deducted from prize payments of $5,001 or more. State<br />
taxes (at the current rate) are automatically deducted<br />
from prize payments of $2,000 or more. This may not<br />
be your entire tax liability. Please consult your tax<br />
advisor for further assistance. Withholding rates are<br />
subject to change. (See mandatory information<br />
regarding not providing a social security number.)<br />
Item 16 Winner’s release authorization. Consistent with<br />
State of <strong>Wisconsin</strong> Open Records law, s. 19.31 to<br />
19.39, Stats., the <strong>Lottery</strong> may use your name, likeness<br />
and/or town of residence, in public information efforts<br />
without compensation to you. Upon claiming your prize,<br />
you release the <strong>Wisconsin</strong> <strong>Lottery</strong> and its representatives<br />
from any and all liability which may result from<br />
the use or release of the information.<br />
• You may call (608) 267-2839 for further information.<br />
• Jackpot Prizes resulting in annuity or cash option choices<br />
must be claimed at the Madison office. Please contact <strong>Lottery</strong><br />
Player Relations at (608) 261-4916 prior to claiming your ticket.