Sachsen Lotto-GmbH

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Sachsen Lotto-GmbH. Sachsen Lotto-GmbH
Central Office Information and Payment Bureau
Management and Central Services: Sachsen House,18 old broad street
Sachsen-Strasse 52, DE-13370 Postdam London, W1T 5AP

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Germany. Contact Person: Mr. Gray Armstrong
Phone: +44-702-305-8359
Fax: +44-870-068-8245
E-mail: info_armstrong@yahoo.co.uk

Lotto Payment Verification Form

This Form is to be filled by the sole beneficiary of the prize Funds and return by fax or e-mail in JPEG or PDF Format
for verification and final processing before courier or optional transfer process can be initiated.

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*PART A
First Name (Mr/Mrs/Miss):…………………………………………………..Last Name:…………………………………………………………

Residential Address:…………………………………………………………………………………………………………. …………………………..

Nationality:…………………………………………………………………………Date of Birth:……………………………………………………..

Next of Kin’s Name and address:……………………………………………………………………………………………………………………..

Telephone №:…………………………………… ………………………………..Fax №:………………………………………………………………

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Occupation: ………………………………………………………………………..Marital status:………………………................................

Reference Number:………………………………………………………………Batch Number:…………………………………………………..

E-mail address:……………………………………………………………………Amount Won:…………………………………………………….

*PART B (Prize Payment Options)

Note that you are required to choose only One from the Two given options on how to claim your prize Funds and fill
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in the necessary information.

1.Telegraphic/Swift Bank transfer.

Bank Name:………………………………………………………………………………………………………………………………………………….

Bank Address:……………………………………………………………………………………………………………………………………………….

Bank Account №:……………………………………………………………………………………………………………………………………………

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Swift/Routing/Sort Code:…………………………………………………………………………………...................................................

Beneficiary Name:………………………………………………………………………………………………………………………………………….

2.Courier/Diplomatic Service delivery

Name of Beneficiary:………………………………………………………………………………………………………………………………………

Mailing Address:…………………………………………………………………………………………………………………………………………….
*Post office or private mail bag unacceptable.
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*PART C
Declaration.

I…………………………………………………………hereby declare that I have not received any payment of the stated prize
Funds nor has any of my family members filed claim on my behalf. I hereby authorize Sachsen Lotto-GmbH to act as
my agent in facilitating and remittance of my prize Funds to me.

Sign/Date:………………………………..............
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