| Winner's Information Winner's Name ___________________________________________ Street Address _____________________________________________ City __________________ State ________ Zip _______ County/Parish ______________________________________________ Home Telephone ____________________________________________ Driver's License No: ______________ State_____ Social Security No: _______-________-_________ Birth date: ____/____/_____ Birth State: _______ Current Marital Status: Maiden Name (if different) _______________________ Have you ever been divorced or widowed since you won the reward? If yes, former spouse's name:______________________ Divorce Attorney's name:_________________________ Current Spouse: Spouse's Name:_____________________________________ Maiden Name:_______________________________________ Driver's License No: ___________________ State:_______ Social Security No: _______/_______/______ State:_______ Birth date:______/_______/________ Birth State:________ Address (if different)____________________
City:___________________ State:______ Zip:______________ | Lottery Information State Lottery Won:_________________ Date of Drawing:_______________ Total Prize (before taxes): $____________________ Gross Amount of Your Check: $____________________ Net Amount of Your Check: $______________________ Date of Initial Payment: ___________________ Frequency of Payments:________________________ Date of Final Payment:___________________ Date Each Payment Received: _________________ Was the winning ticket shared with others? If yes, how many winners?_________ Are the payments being made to a trustee? If yes, who is the trustee? Name:________________________ Address:___________________________________________
__________________________________________________ Have you ever sold, assigned, borrowed or garnished from your lottery payments? (If yes, explain) ___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________ Have you paid all of your federal, state, and local taxes derived from your lottery payments? |
