You are required to complete all details on this form for verification to take place.

You must satisfy all eligibility requirements outlined

in the terms and conditions of the relevant promotion to be awarded a prize. Lottery retail outlet owners and employees of lottery
retail outlets may not be eligible to win a promotional prize. Refer to the terms and conditions of the promotion for further detail.

Name of promotion Lottery game/Instant Scratch-Its ticket

Game and ticket number

Personal Details
Customer’s name

Customer’s address

Postcode Phone number Email address

Prize Payment Bank Details

Financial institution Account name

Branch address

BSB Account number

*Please note, any changes, alterations including whiteout to bank details must be initialled by the Claimant.

The personal information we collect in this form is done so for the purposes of providing you with our products and services including the processing of this prize claim form. If we cannot
collect your personal information, we will not be able to process your claim. The personal information we collect may be disclosed to other entities in The Lottery Corporation Group, a third
party as required by law and to third parties who assist us in running our business. Some of these third party service providers may be located offshore. For more information about these
offshore disclosures, our handling practices and details about how you may access and seek correction of your personal information or make a complaint please refer to our Privacy Policy
located at www.thelotterycorporation.com/privacy
New South Wales Lotteries Corporation Pty Limited
ABN 27 410 374 474 | ACN 142 890 195
Administration, Level 29, 680 George Street, Sydney NSW 2000 131 868
Administration, Locked Bag 10008, Sydney NSW 2001 thelott.com
STATUTORY DECLARATION
OATHS ACT 1900
I,

(Full name of declarant)

of

(Address)

in the state of New South Wales do solemnly and sincerely declare that:

1. I am the person named in the Personal Details section of this form;

2. My date of birth is ________ day of __________________year____;
3. Yes, I can confirm that I have provided a certified copy of my drivers licence or a certified copy of my birth certificate;
4. Yes, I confirm I am not a Lotteries Retailer, or employed by any Lotteries Retailer; and
5. I have met all of the terms and conditions of the promotion for which I am now claiming a prize, including but not limited to entry
and prize eligibility requirements.

And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the provisions of the Oaths Act
1900 (NSW).

Declared at _____________________________on this ________ day of________ 20 ___ .

(Location)

_________________________________________
(Signature of declarant)

in the presence of an authorised witness, who states:

I, _____________________________________ , a _______________________________________________________________
(Name of authorised witness) (Qualification of authorised witness)

certify the following matters concerning the making of this statutory declaration by the person who made it: [*please cross out any
text that does not apply]

1. *I saw the face of the person OR *I did not see the face of the person because the person was wearing a face covering,
but I am satisfied that the person had a special justification1 for not removing the covering, and

2. *I have known the person for at least 12 months OR *I have confirmed the person’s identity using an identification
document and the document I relied on was ……………………………………………………….
(Describe identification document relied on)

_____________________________________________ ________________________________________________
(Signature of authorised witness) (Date)

1. The only “special justification” for not removing a face covering is a legitimate medical reason (at September 2018)

The personal information we collect in this form is done so for the purposes of providing you with our products and services including the processing of this prize claim form. If we cannot
collect your personal information, we will not be able to process your claim. The personal information we collect may be disclosed to other entities in The Lottery Corporation Group, a third
party as required by law and to third parties who assist us in running our business. Some of these third party service providers may be located offshore. For more information about these
offshore disclosures, our handling practices and details about how you may access and seek correction of your personal information or make a complaint please refer to our Privacy Policy
located at www.thelotterycorporation.com/privacy
New South Wales Lotteries Corporation Pty Limited
ABN 27 410 374 474 | ACN 142 890 195
Administration, Level 29, 680 George Street, Sydney NSW 2000 131 868
Administration, Locked Bag 10008, Sydney NSW 2001 thelott.com
Office Use Only
Draw Administration

Date received Processed by Signature PV number

Prize amount

Prize Administration

Date received Entered by Signature Claim tracker ID

Prize verified by Date Prize authorised by Date

The personal information we collect in this form is done so for the purposes of providing you with our products and services including the processing of this prize claim form. If we cannot
collect your personal information, we will not be able to process your claim. The personal information we collect may be disclosed to other entities in The Lottery Corporation Group, a third
party as required by law and to third parties who assist us in running our business. Some of these third party service providers may be located offshore. For more information about these
offshore disclosures, our handling practices and details about how you may access and seek correction of your personal information or make a complaint please refer to our Privacy Policy
located at www.thelotterycorporation.com/privacy
New South Wales Lotteries Corporation Pty Limited
ABN 27 410 374 474 | ACN 142 890 195
Administration, Level 29, 680 George Street, Sydney NSW 2000 131 868
Administration, Locked Bag 10008, Sydney NSW 2001 thelott.com