GOVERNMENT OF PUNJAB

DIRECTORATE OF PUNJAB STATE LOTTERIES

S.C.O. No. 106- 108, SECTOR -17-D, CHANDIGARH
Claim form for the prize winner (s) of Punjab state
__________________
Held on___________________
1.
Name of the winner (S) ___________________________________
(In Block Letters)
2.
Minor or Major
___________________________________
3.
Fathers/ Husband Name
___________________________________
4.
Permanent Address
____________________________________
(In Block Letters)
5.
Present Address
___________________________________
6.
Telephone/ Mobile Number ___________________________________
7.
Occupation
___________________________________
8.
Pan Number
___________________________________
9.
Prize winning Ticket/
Coupon Number
___________________________________
10. Date of Draw
___________________________________
11. Amount of Prize
___________________________________
12. Detail of Account to which
the prize Amt to be transferred.
a) Nature of Account _________________________
b) Account No
_________________________
c) Name of Bank
_________________________
d) Address of Bank
________________________
e) IFSC Code of bank _________________________
(Please enclose a cancelled cheque )
Date
Claimant

Signature of

Advance Receipt
Received a sum of Rs. _______________ Rs.___________________________
from Director Punjab State Lotteries, Chandigarh being the prize
amount
against
Ticket
No.
__________
of
Punjab
State_________________________Draw held on ___________________
Signature of the
Claimant
(With Revenue Stamp)
Instructions
1.
Affix three passport size Photographs with Claim Form out of
which two should be duly attested by 1st Class Magistrate/
Notary Public/ Oath Commissioner any Gazetted Officers.
2.
Please enclose a cancelled cheque of account where the
winning amount is to be transferred.
3
In case of Claimant is Minor than an Affidavit from the National
Guardian/ Parent should be attached with the Claim Form.

4.

In case Prize is not claimed within the prescribed period (30

days from the date of Gazette Notification) then reasons of this
on an Affidavit should be attached with the claim Form.