GROUP BUYING AGREEMENT

We, the undersigned, hereby declare that we are the joint owners in the proportions shown opposite our respective names of the Lottery tickets described below. Each of the tickets mentioned shall be endorsed as follows: __________________________________________________________________
(Name of one person in trust for group name or all the names listed hereunder)

and if one or more tickets should qualify as a winning ticket, payment or delivery of any prize pursuant to the applicable rules and regulations and Game Conditions of Western Canada Lottery Corporation (WCLC) or Interprovincial Lottery Corporation (ILC) shall be made to the person whose name is so endorsed on the ticket and for so doing this shall constitute the full and sufcient authority to WCLC or ILC, as the case may be. The undersigned and each of them hereby releases WCLC and ILC from any claim with respect to money so paid or prize or prizes so delivered; and hereby specically consents to the publication of his or her name, city or town of residence, photograph or picture, and releases WCLC and ILC from any claim with respect to or arising out of such publication. As between themselves only, any prize or prizes shall be shared among the undersigned in the proportions stated below and each of the undersigned acknowledges that, in case of death, their respective rights in the said tickets shall pass to their estate. Dated at _____________________________________, this _________ day of ______________________________, ____________.
(city/town, province) (month) (year)

LOTTERY TICKET INFORMATION

LOTTO MAX, WESTERN MAX, LOTTO 6/49, WESTERN 649, EXTRA, PROLINE, OVER/UNDER, POINT SPREAD, DOUBLE PLAY, POOLS, PROPS, OTHER Type of Game Date of Draw or Sports Event(s) Ticket Number / Control Number
(18-digit number located at top of ticket)

JOINT OWNERS IDENTIFICATION

Name Address & Phone Number Signature Share (%)

The joint owners acknowledge that this form is provided by Western Canada Lottery Corporation as a convenience only, and does not impose nor imply, nor does Western Canada Lottery Corporation accept, any legal liability whatsoever for its content. WCLC 1936 01/2013