APPLICATION FOR LOTTERY PRIZE CLAIM PDF Free Download
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APPLICATION FOR LOTTERY PRIZE CLAIM
Prize Winning Ticket No.: ___________________________________________
Name of Lottery: ____________________________________________________________
Draw No.: _____________________ Draw Date : _______________________________
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I HEREWITH SUBMIT MY PRIZE WINNING TICKET FOR YOUR KIND CONSIDERATION.
Full Name of The Prize winner: __________________________________________________________
Address : __________________________________________________________
: __________________________________________________________
: __________________________________________________________
: __________________________________________________________
: __________________________________________________________
: __________________________________________________________
Father's/Husband's Name : __________________________________________________________
Profession : Business or Service
Name of the Organization : __________________________________________________________
Nature of Business : __________________________________________________________
Rank of the Prize : __________________________________________________________
Prize Amount : __________________________________________________________
My PAN No. is : _______________________________________________ (Xerox Copy)
My Contact No. is : __________________________________________________________
My Bank Account No. is : __________________________________________________________
: IFSC Code_____________________________
Bank Name & Branch :___________________________________________________________
________
Signature
Passport
Size Photo
Institutional Finance & State Lottery
The Director
Government of Mizoram, Tuikhuahtlang,
Aizawl 796001, Mizoram.
Enclosed: (1)
To,
Original Prize Winning Lottery Ticket
(2)
Affidavit duly attested by 1st Class Magistrate/ Notary
(3) Photo Copy of PAN
(4) Photo Copy of Bank Pass Book/ Crossed Cheque
Email:
1. All claims of Taxable Prizes should be submitted to The Director,
Institutional Finance & State Lottery in the prescribed form.
2. The form should be filled clearly showing the Name of the claimant,
Postal Address, Name of the Lottery, Prize amount, PAN Number,Contact
Number and Bank details like Bank Account Number, IFSC code, Name of
the Bank and Branch, cancelled Cheque etc.
3. Original prize winning Ticket with one photocopy duly attested by a
Gazetted Officer/Notary Public, an affidavit of ownership of the
prize winning ticket from any 1st Class Magistrate/Notary Public should
also be submitted.
4. Government of Mizoram shall not be liable to pay prizes on tickets lost
in postal transit, defaced or mutilated.
5. Tampered tickets shall not be entitled to any prize and any person
claiming prize money with a tampered ticket is liable to be sued in a
court of law.
6. The Director shall disburse Prize Money for accepted genuine claims
after making necessary deduction of Income Tax etc. in the form of
Demand Draft/ Cheque/ RTGS.
PRIZE CLAIM INSTRUCTIONS
Director
Institutional Finance & State Lottery
Aizawl, Mizoram.
FORMAT OF AFFIDAVIT TO BE SUBMITTED BY WINNERS (DULY ATTESTED BY NOTARY PUBLIC)
ALONG WITH RESPECTIVE CLAIM FORMS.
A F F I D A V I T
I, ……………..……….., aged about ….. years, son / daughter of Shri. ………………… resident of
……………………………………... …………………………………………………………………….. do hereby
solemnly affirm and declare as follows:
1. That I am a bonafide citizen of India by birth.
2. That I am the Sole Owner of Prize Winning Ticket No. ……………….. of ……………………………….
Lottery of Draw No. ……………. Dated ………… of the ……… (prize rank) Prize of Rs. ……………. of
Government of Mizoram.
3. That I will not claim the other prize or whatever I am not entitled to.
4. That I am the bonafide / genuine claimant of the …… Prize of ……………… lottery.
5. That there are no other claimant / winner of the Prize Winning Ticket No. ……………. of draw
dated …………………. of ………………………. Lottery.
6. I have agreed and giving my consent that by signing this claim form and claiming the prize
amount, my name, my locality, my photograph and the prize amount become public information for
publicity purposes.
That the above facts are true to the best of my knowledge and belief.
Dated the ________________ day of _________________.
DEPONENT
Verified, affirmed and signed before me at _____________ on ______________.
DEPONENT
