WINNER CLAIM FORM
** SIGN THE BACK OF YOUR TICKET **
THIS FORM MUST BE SUBMITTED WITH THE
WINNING TICKET TO THE KANSAS LOTTERY.
INCOMPLETE FORMS WILL BE RETURNED.
(Print Legibly)
Last Name:
Firs
t Name:
Address:
City: State: Zip:
Mailing Address (If different than above):
Mailing City: Mailing State: Mailing Zip:
SSN/ITIN: Gender: Male Female
Date of Birth: Phone:
U.S. Citizen: Yes No
Amount of Prize: $ Ticket Number:
All information which I have furnished on this form (including my name, address, taxpayer or social security number) is accurate, true,
and correctly identifies me as the recipient of the prize being claimed; I have legally obtained rights to the prize I am claiming, that I am
the lawful owner, and that I am not legally prohibited by law from making a claim or claiming a prize; I understand that any person who
falsely makes, alters, forges, conceals their true identity upon, steals, embezzles, makes a fraudulent or illegal claim with, or
counterfeits a Kansas Lottery ticket is guilty of one or more crimes, punishable by possible imprisonment; I indemnify and hold harmless
the Kansas Lottery for any loss or expense it might incur if any of the information I have provided is not true and accurate.
I declare under penalty of perjury that the foregoing is true and correct:
Claimant’s Signature: (REQUIRED)
Date:
W-9 CERTIFICATI
ON
1. The number shown on this form is my correct Social Security Number, and 2. I am not subject to backup withholding because: (a) I
am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of a
failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a
U.S. person (including a U.S. resident alien).
Claimant’s Signature: (REQUIRED)
Date:
Bring or mail the ticket and completed claim form to:
Kansas Lottery Claims
128 N. Kansas Ave
Topeka, KS 66603
For more information, visit us at
www.kslottery.com or call 800-322-5688.
