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Get Hoosier Form J-06 2013-2024

WINNER CLAIM FORM MAIL TO HOOSIER 1302 N. MERIDIAN ST. INDIANAPOLIS IN 46202 1-800-955-6886 FOR USE ONLY DATE CLAIM NO. RETAILER NO. INSTRUCTIONS TO CLAIMANT YOU MUST SIGN YOUR NAME ON THE BACK OF TICKET. ON BACK OF TICKET PRINT YOUR NAME ADDRESS. COMPLETE ITEMS 7 THROUGH 19 BELOW PLEASE PRINT. ADDRESS 9. CITY 10. STATE 11. ZIP CODE 13. NATION 12. COUNTY NAME FOR CLAIMANT USE 14. SOCIAL SECURITY NO. 15. DATE OF BIRTH 16. US CITIZEN YES NO The Hoosier is required by federal law to obtain the prize winner s social security number for all prizes 600 or greater in order to report taxes and to comply with IC 4-30-11-11. The final tax amount owed will depend on your personal tax situation. As the Hoosier or its employees cannot provide Initial you with financial advice we suggest you talk with a professional tax advisor. here Under penalty of perjury I hereby declare that to the best of my knowledge and belief the name address and social security number provided correctly identify the recipient s of the payment of the validated winning ticket and that the purchaser of the ticket is not prohibited by law from purchasing a ticket. WINNER CLAIM FORM MAIL TO HOOSIER 1302 N* MERIDIAN ST. INDIANAPOLIS IN 46202 1-800-955-6886 FOR USE ONLY DATE CLAIM NO. RETAILER NO. INSTRUCTIONS TO CLAIMANT YOU MUST SIGN YOUR NAME ON THE BACK OF TICKET. ON BACK OF TICKET PRINT YOUR NAME ADDRESS* COMPLETE ITEMS 7 THROUGH 19 BELOW PLEASE PRINT. STAPLE TICKET TO THE FRONT OF THE CLAIM FORM. MAIL THE CLAIM FORM TO THE ABOVE ADDRESS* KEEP A COPY OF CLAIM FORM AND TICKET FOR YOUR RECORDS* PROVIDE A COPY OF A GOVERNMENT ISSUED PICTURE I. D. For your protection we suggest you mail your claim by certified mail* FOR USE ONLY CIRCLE ONE DRAW GAME 1. TICKET NO. OR CASHIER S INITIALS CHECK NO. TO TOP COPY HERE PLEASE DO NOT STAPLE THROUGH ANY NUMBERS OR PLAY SPOTS ON TICKET INSTANT GAME 2. DRAW 5. PRIZE AMOUNT 7. NAME LAST NAME - PLEASE PRINT MM-DD-YY 4. GAME TYPE 3. VALIDATION NO. 6. WAGER AMOUNT FIRST NAME MI 8. ADDRESS 9. CITY 10. STATE 11. ZIP CODE 13. NATION 12. COUNTY NAME FOR CLAIMANT USE 14. SOCIAL SECURITY NO. 15. DATE OF BIRTH 16. US CITIZEN YES NO The Hoosier is required by federal law to obtain the prize winner s social security number for all prizes 600 or greater in order to report taxes and to comply with IC 4-30-11-11. Winner claim forms cannot be processed without this information* 17. PHONE NUMBER 18. This prize is claimed as follows A for myself as the sole winner B as a member of the winning group designated on the attached IRS Form 5754 C on behalf of the person s designated on the attached IRS Form 5754 19. The Hoosier will withhold Federal and State taxes at the minimum amount required by IRS regulations and Indiana State Law. It is important to understand that the taxes withheld may not cover all of your Federal or State tax obligations. The final tax amount owed will depend on your personal tax situation* As the Hoosier or its employees cannot provide Initial you with financial advice we suggest you talk with a professional tax advisor.

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