Get AK 0405-858a 2013-2023
58a Rev 04/22/13 Date Won This receipt is required for each prize of $50.00 or more. Game Series (Game No./Name/Price) Amount Won This receipt is required for each prize of $50.00 or more. Game Series (Game No./Name/Price) Date Won Serial Number Amount Won Serial Number Date Won Serial Number Amount Won Name of Prize Winner $ Name of Prize Winner Mailing Address $ Name of Prize Winner Mailing Address City, State, Zip $ Mailing Address City, State, Zip X PULL-TAB PRIZE RECEIPT.
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