Get Kansas Lottery Claim Form

KANSAS LOTTERY WINNER CLAIM FORM For Of cial Use Only On-line and Instant Game Prizes Instant Ticket On-Line Ticket Back of ticket above barcode Front of ticket above barcode Prize Amount Claimed Last Name First Name Address City State Zip Home Phone - - Alternate Phone - - Sex M F Birth Date / / STAPLE WINNING TICKET HERE INSTRUCTIONS 1. Complete the back of your ticket. 2. Complete and sign the Winner Claim Form including W-9 Certi cation* 3. Staple your winning ticket above. 4. Make a copy of Claim Form for your records. 5. Present or mail to Kansas Lottery Claims 128 N Kansas Ave Topeka KS 66603-3638 INFORMATION The information herein and the prize won may be disclosed to various state and federal agencies and will be subject to appropriate federal and state withholdings. Winners of 600 or more will receive a Form W-2G* For more information call 1-800-322-5688 Monday Friday 8 a*m* 5 p*m* SIGNATURE REQUIRED PUBLIC DISCLOSURE AUTHORIZATION // Signature Date I authorize the Kansas Lottery to publicly identify me and release information regarding my prize. I declare under penalties of perjury that all information provided is true and correct. W-9 CERTIFICATION REQUIRED Under penalties of perjury I certify that SSN - - 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 noti ed by the Internal Revenue Service 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 noti ed me that I am no longer subject to backup withholding and 3. I am a U*S* person including a U*S* resident alien. Certi cation instructions. You must cross out item 2 above if you have been noti ed by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return* If you do not have a social security number or are not a U*S* person please contact the Lottery at 1-800-322-5688. Date // Signature Received / Reviewed Processed Of ce FOR OFFICIAL USE ONLY WEB Winner Claim Form - W-9 KSL Rev 4/04 kr/mt Intranet Userstore general folder. Complete the back of your ticket. 2. Complete and sign the Winner Claim Form including W-9 Certi cation* 3. Staple your winning ticket above. 4. Make a copy of Claim Form for your records. 5. Present or mail to Kansas Lottery Claims 128 N Kansas Ave Topeka KS 66603-3638 INFORMATION The information herein and the prize won may be disclosed to various state and federal agencies and will be subject to appropriate federal and state withholdings. Staple your winning ticket above. 4. Make a copy of Claim Form for your records. 5. Present or mail to Kansas Lottery Claims 128 N Kansas Ave Topeka KS 66603-3638 INFORMATION The information herein and the prize won may be disclosed to various state and federal agencies and will be subject to appropriate federal and state withholdings. Winners of 600 or more will receive a Form W-2G* For more information call 1-800-322-5688 Monday Friday 8 a*m* 5 p*m* SIGNATURE REQUIRED PUBLIC DISCLOSURE AUTHORIZATION // Signature Date I authorize the Kansas Lottery to publicly identify me and release information regarding my prize.