Fillable WINNER CLAIM FORM CLAIMANT - COMPLETE THIS SECTION (New York State)

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WINNER CLAIM FORM CLAIMANT - COMPLETE THIS SECTION (New York State)

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The WINNER CLAIM FORM CLAIMANT - COMPLETE THIS SECTION (New York State) form is 2 pages long and contains:

  • 2 signatures
  • 20 check-boxes
  • 33 other fields

Country of origin: US
File type: PDF

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US/Foreign Passport
Driver License or Non-Driver ID
Driver Learner Permit
Government ID
Certificate of Naturalization
Certificate of Citizenship
Permanent Resident Card (Green Card)
Birth Certificate and a form of photo ID with name
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New York State Benefit ID Card
MTA Reduced Fare MetroCard
CLAIM NUMBER ________________________ PROCESSED BY ________________________________________ DATE ________________
PRIZE AMOUNT __________________________ CHECK AMOUNT __________________________________ CHECK NUMBER _______________
IDENTIFICATION TYPE ____________________________ IDENTIFICATION NUMBER __________________ EXPIRATION DATE ______________
CLAIMANT - COMPLETE THIS SECTION All information must be completed. PLEASE PRINT CLEARLY.
12. Are you a Bronx, Brooklyn, Manhattan, Yes No 13. Are you a Yonkers resident? Yes No
14. Do you own a store that sells lottery? Yes No 15. Are you employed by a lottery retailer/sales agent? Yes No
16. Are you related to someone who owns or works at a lottery retailer/sales agent? Yes No
ACCEPTABLE FORMS OF PHOTO IDENTIFICATION
PLEASE COMPLETE PAGE 2
WINNER
CLAIM FORM
Mail to:
N.Y.S. Gaming Commission, Division of Lottery
P.O. Box 7533
Schenectady, NY 12301-7533
Prize Claim Questions:
518-388-3370
Instructions on the Back of this Form
For more information, visit our website at www.nylottery.ny.gov
1. Legal Last Name First Name Middle Sux Jr, Sr, II
2. Claimant Type (Check one) Individual Corporation Partnership Trust Other
5. State 6. Zip Code
9. Residency/Citizenship (Check one) 10. Telephone Numbers
Primary
Secondary
11. Email
Multiple Claimants
Each claimant must complete a separate claim form.
MM-DD-YYYY
(Enter country of citizenship below)
(Provide SSN or Federal Taxpayer ID Number in #7 above)
US Resident/Resident Alien
Non-Resident Alien
17. If “yes” to #14, #15, or #16, provide store name and address.
18. Are you 18 years of age or older? Yes No If no, see - N.Y.S. Tax § 1613(b)
8. Date of Birth
All must be valid and current.
FOR LOTTERY USE ONLY
Street # Street Name Apt./suite/oor #
7. U.S. Social Security Number or Federal Taxpayer Identication Number
Queens or Staten Island resident?
3. Address
4. City
Social Security Card or Federal Taxpayer ID Certication
must be presented with these forms of ID.
Rev V.2 10/2020
Complete information requested on the back of winning ticket(s).
Complete this claim form and sign.
Enclose winning ticket(s)/voucher(s).
Enclose copy of Acceptable Forms of Identification (Must be valid and current).
PAGE 2
PLEASE READ AND SIGN
Mail to:
N.Y.S. Gaming Commission, Division of Lottery
P.O. Box 7533
Schenectady, NY 12301-7533
Allow approximately 15 business days for processing. Jackpot prize of $250,000 or more may take longer.
Personal Information Notice: For the purpose of ensuring lawful distribution of New York Lottery prizes, the New York State Gaming Commission
(“Commission”), which operates the New York Lottery, requires the mandatory disclosure of your personal information, including your Social Security
Number or Taxpayer Identification Number, to determine statutory offset liability for prizes over $600 pursuant to New York State Tax Law §§ 1613-a,
1613-b and 1613-c. Disclosure of your personal information is also required to administer federal and New York State income tax laws for prizes over
$5,000, including, without limitation, Internal Revenue Code § 3402(q) and New York State Tax Law § 671. If you do not provide your personal
information, your entry may not be processed, your claim may be denied, you may not be awarded a prize, or the law may require taxes to be withheld
at a higher rate from any lottery winnings than would be withheld if your taxpayer identification number is provided. The Commission’s Director of Prize
Payments is the custodian of prize claim records and may be contacted at One Broadway Center, PO Box 7533, Schenectady, NY 12301-7533 or by
phone at (518) 388-3370.
If you are a U.S. Resident: By signing below, I am stating, under penalties of perjury, that I am the lawful owner of the ticket(s)/voucher(s) identified
above and the information I have provided in this claim form is true, correct and complete. I understand that New York Lottery prizes are public funds
and that prize winners like me must be publicly announced to maintain public confidence in the New York Lottery. I agree to participate in a news
conference to announce my prize, unless the Commission decides otherwise.
W-9 Certification – Under penalties of perjury, I certify that (1) the number shown on this form is my correct taxpayer identification number
(TIN), (2) I am not subject to backup withholding due to failure to report interest and dividend income, and (3) I am a U.S. person as defined
by the I.R.S. (For federal tax purposes, a U.S. person includes but is not limited to: an individual who is a U.S. citizen or U.S. resident alien; a
partnership, corporation, company, or association created or organized in the United States or under the laws of the United States; any
estate (other than a foreign estate); or a domestic trust (as defined in 26 C.F.R. 301.7701-7)).
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid
backup withholding.
U.S. RESIDENT/RESIDENT ALIEN
CLAIMANT’S
SIGNATURE___________________________________________________________________________________ DATE __________________
If you are a Non-Resident Alien: By signing below, I am stating, under penalties of perjury, that I am the lawful owner of the ticket(s)/voucher(s)
identified above and the information I have provided in this claim form is true and correct. I understand that New York Lottery prizes are public funds
and that prize winners like me must be publicly announced to maintain public confidence in the New York Lottery. I agree to participate in a news
conference to announce my prize, unless the Commission decides otherwise.
NON-RESIDENT ALIEN
CLAIMANT’S
SIGNATURE___________________________________________________________________________________ DATE __________________
You may want to make a copy of the front and back of your ticket(s) as well as your signed claim form and use registered mail to track
your mailing.
WINNER CLAIM FORM CHECKLIST FOR MAIL-IN CLAIMS
US/Foreign Passport
Driver License or Non-Driver ID
Driver Learner Permit
Government ID
Certificate of Naturalization
Certificate of Citizenship
Permanent Resident Card (Green Card)
Birth Certificate and a form of photo ID with name
US Military ID
New York City ID
New York State Benefit ID Card
MTA Reduced Fare MetroCard
Social Security Card or Federal Taxpayer ID
Certication must be included with these
forms of ID.
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WINNER CLAIM FORM CLAIMANT - COMPLETE THIS SECTION (New York State)

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Completed 16 January 2021

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