14. DISTRICT OFFICE NO. 15. RECEIVED BY (Signature) 16. DATE
17. TYPE OF I.D. TYPE OF I.D.
NUMBER NUMBER
18. INSTANT TICKET NUMBER 19. INSTANT TICKET VALIDATION NUMBER
(on back of ticket above the bar code) (covered number on the lower play area)
20. ON-LINE TICKET SERIAL NUMBER (on the bottom front of the on-line ticket)
21. Processed By: Date: 22. Prize Amount: $ 23. CheckAmount: $
Check No: Received By: Date:
Claimant Signature
1. NAME AS LISTED WITH THE INTERNAL REVENUE SERVICE
MR.
MS.
3. ADDRESS
4. CITY 5. 5. STATE 6. 6. ZIP CODE
7. COUNTY
OR
8. 8. DATE OF BIRTH
MM-DD-YYYY
CLAIMANT - COMPLETE THIS SECTION
PROVINCE
U.S. CITIZEN/RESIDENT ALIEN
OTHER
(IF YOU CHECKED “OTHER” PROVIDE COUNTRY OF CITIZENSHIP)
CLAIMANT’S PERSONAL IDENTIFICATION
FOR LOTTERY USE ONLY:
HOME
OTHER
11. E-MAIL
10. PHONE NUMBERS
12. U.S. SOCIAL SECURITY NUMBER OR TAX IDENTIFICATION NUMBER
13. CLAIMANT SIGNATURE DATE
2. CLAIMANT TYPE (CHECK ONE)
INDIVIDUAL CORPORATION PARTNERSHIP TRUST OTHER
9. CITIZENSHIP
(CHECK ONE)
number shown on this form is correct, b) I am not subject to backup withholding due to failure to report interest and dividend income, c) all other above informa-
Or Mail to:
For more information, visit our website at www.galottery.com
If a person wins a prize of $250,000 or more, O.C.G.A. §50-27-25(d) authorizes that person to keep that prize anonymous. Do you wish to remain anonymous for your
winning of this prize of $250,000 or more? Yes No
9-W mroF etutitsbuS
24.
CLAIM NUMBER
White Copy - Georgia Lottery Canary Copy - Claimant Copy
INSTRUCTIONS TO FILE YOUR WINNER CLAIM FORM:
1 through 5 below.
1.) Complete and sign the back of the ticket. The ticket must be completed in the name of one individual or legal entity
(i.e., Corporation, Partnership, etc.)
2.) Complete the Claimant Section of the Winner Claim Form (1 through 13). The Winner Claim Form must be completed
as a representative of a legal entity, provide your title.
social security number, preferably a Driver’s License and Social Security Card. The combined forms of I.D. must
verify your name, signature and social security number.
issued by another State
250 Williams Street
(404) 215-5000
5155 Columbia Road
Suite 103
(706) 737-1320
Suite 21
(706) 278-3088
Columbus
(706) 660-2380
North & South Baggage Claim
(Claim up to $25,000 - call for extended hours)
(404) 762-8842
GLC-100 Revised 8/16/19 (Back)
5.)
Retain a copy of the completed Winner Claim for your records.
Suite 800
(770) 923-0220
1693 Bass Road
(478) 784-5420
Savannah
(912) 920-5100
Tifton
Suite 101
(229) 382-2430
For more information visit our website at www.galottery.com or call:
