Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to access the form and open it in the online editor.
2. Enter the licensee's name in the appropriate field to identify the gaming entity that issued the receipt.
3. Fill in the patron's name, ensuring it matches the identification provided for the jackpot claim.
4. Complete the address field with the patron's current address, including the city, state, and zip code.
5. Input the amount of the jackpot won in the designated section, ensuring accuracy as this figure will be crucial for any further payments.
6. Fill out the date the receipt is issued to document when the receipt was created.
7. Indicate the date the jackpot was paid or voided, marking whether the payment has been completed.
8. Secure necessary signatures: have the cashier and gaming manager sign and date the form where indicated.
9. Under the 'Note to Patron' section, read and agree to the declaration which confirms your identity and entitlements.
10. Sign and date the form in the specified area to affirm the information provided is correct.
11. Finally, save your changes, then download, print, or share the completed form as required.

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