Verification & Claims Release Form

Please read these instructions carefully

1. This application is for the verification and transfer of your winnings. All information given must be correct.
Any changes in status should be reported to our office for rectification immediately.
2. Complete this form in black or blue ink BLOCK capitals and return by email or fax.

Data Protection: The personal data collected here will be used for identification and verification purposes only.
Please note that this information would be kept highly secure and confidential.

1. Winning Information:

Reference Number:

Batch Number: Serial Number:

2. Beneficiary Information:

Title: Dr Mr Mrs Miss Ms

Full Name(s):
(These names must be the same as the names on your passport/National Identity Card)

Address:

City: State: Post code:

Country:

Tel/Fax Number: Mobile:

Email Address:

Date of Birth: Sex:

Place of Birth: Nationality:

Occupation:

Marital Status:

©2016 Global Subscribers. All rights reserved Page 1 of 3

3. Funds Remittance Option (please tick preferred option):

Our payment process involves your making a choice from the under listed options of remittance:

A. Cash Pickup: Personally collect your winnings directly from our Payment Centre in the UK.

B. Wire Transfer*: Have your prize money transferred to any designated bank account of your choice
from your online account setup for you on our website.

4. Documents Checklist:

I have attached a copy of my Identification (Driver’s license/ International passport/National Identity Card).

I have attached a Proof of Residence (Utility bill or Bank statement).

Declaration:

1. I certify that the information provided on this Form is complete, true and accurate.

2. I understand that the personal data on this Form is collected for the purposes of identification and
verification purposes only, and I consent for this data to be processed and stored for the purpose of such
administration.

Signature: Date:

The disbursement of your winnings complies with the Anti-Fraud Section 2, Sub-Section (IV) of the procedural
manual of the funds disbursement agreement existing between Lottery companies and International Monetary
rules and regulations.

©2016 Global Subscribers. All rights reserved Page 2 of 3

DO NOT WRITE BELOW - For Official use only
********************************************************************************************************
********************************************************************************************************

Approval: YES NO

Details:

Authorizing Officer:

Signature: Date:

©2016 Global Subscribers. All rights reserved Page 3 of 3