Yesterday

FORM

WINNER CLAIM FORM

DOL 173-2

REV. 02/2011

STAPLE WINNING TICKET HERE

Privacy Act Notice and Instructions are on the Back of this Form

For more information, visit our Web site at flalottery.com

PLEASE DO NOT STAPLE

THROUGH ANY NUMBERS,

BARCODE, OR PLAY AREA

ON THE TICKET

CLAIMANT – COMPLETE THIS SECTION

1. NAME AS LISTED WITH THE INTERNAL REVENUE SERVICE

MR

MS

MIDDLE

FIRST

LAST

2. U.S. SOCIAL SECURITY OR TAXPAYER IDENTIFICATION NUMBER

3. CLAIMANT TYPE:

INDIVIDUAL

CORPORATION

PARTNERSHIP

TRUST

ESTATE

NON-PROFIT

INDIVIDUAL CLAIMING FOR A GROUP - IRS FORM 5754 MUST ACCOMPANY PRESENTED CLAIM

4. DATE OF BIRTH (MM-DD-YYYY)

5. ADDRESS

6. CITY

7. STATE

8. ZIP

9. COUNTY

10. CITIZENSHIP (CHECK ONE)

11. TELEPHONE

U.S. CITIZEN/RESIDENT ALIEN

HOME

NON U.S. CITIZEN

BUSINESS

OTHER

COUNTRY OF CITIZENSHIP

12. EMAIL

I understand that any person who knowingly presents a counterfeit or altered lottery ticket; or who, with intent to defraud, falsely

makes, alters, forges, passes or counterfeits a lottery ticket, or who knowingly files a claim based on facts that are untrue, is in

violation of Section 24.118(3), Florida Statutes, and is guilty of a felony of the third degree.

CERTIFICATION

Under penalties of perjury, I certify that 1) the number shown on this form is my correct taxpayer identification number (or I am

waiting for a number to be issued to me), and 2) I am not subject to backup withholding because: (a) I am exempt from backup

withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result

of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

3) I am a U.S. person (including a U.S. resident alien).

DATE

13. CLAIMANT SIGNATURE

FOR LOTTERY USE ONLY:

LOTTERY OFFICE

RECEIVED BY

DATE

ID TYPE/NUMBER

SOD...