GOVERNMENT OF KERELA

DIRECTORATE OF STATE LOTTERIES

KOHIMA :: KERELA
APPLICATION FOR LOTTERY PRIZE CLAIM
Please Tick Below
Upto ₹ 10,000/-
Prize Winning Ticket No. :
Above ₹ 10,000
Lottery Name :

Draw No : Draw Date :

Please Tick Below (This form shall be submitted by the claimant personally in digital mode only)
Nagaland West Bengal Camp Maharashtra Camp Punjab Camp Sikkim Camp online(through website)
The Director, The Nodal Officer, The Nodal Officer, The Nodal Officer, The Nodal Officer, The Nodal Officer,
Directorate of kerela West Bengal Camp, Shop No.17, G.Flr, B2- 1370, Room G.Flr, Changma House, If you have purchased
State Lotteries, Nagaland House, Harmony Mall, C Wing, No.4, 2nd Floor,Arya Upper Syari, Near Royal the lottery through official
P. R. Hill Junction, 1st Floor, LA - Block, Plot No.1 Link Road,Goregaon, Mohalla, Arya Plaza Hotel, website,you have to tick this
Kohima – 797 001, No. 6,Salt Lake, (West) Bhagat Singh School Road, Gangtok,East checkbox
Nagaland. Sector- III, Nagar,Mumbai – 400 104 Ludhiana, Sikkim – 737 102
Kolkata – 700 098. Punjab- 141008

I HEREBY SUBMIT MY PRIZE WINNING TICKET FOR YOUR KIND CONSIDERATION.

Full Name of the Prize winner :

Permanent Address :

Father’s / Husband’s Name :

Profession :
Name of the Organization :
Nature of Business :
Rank of the Prize :
Prize Amount :
PAN Number :
Contact Number :
Aadhaar No :
Bank Account Number :
IFSC Code :
No. of Claims made in the current FY :

Whether any claim made prior to this Yes No

I enclose herewith the original signed ticket on its reverse side along with the Self Declaration in the specified format.
I further enclose an Affidavit, Pan Card, one ID proof, 3 passport sized photographs (not older than 3 months) and a
cancelled cheque leaf of my bank account, and I am also aware that the Directorate of State Lotteries can publish my
personal details, such as name, address and my photograph in the newspapers, magazine, television, radio, social
medias & online websites, outdoor Medias Etc.
No changes shall be made in the format while filling this claim form. If any changes are found, the claim will be returned to the respective winner.
Please read the instructions printed on 2nd Page carefully before filling up the form.

Claimant Signature:

Page 1 of 2
 INSTRUCTIONS FOR CLAIM OF PRIZE MONEY

1. Every winner/claimant should submit his/her claim in the prescribed form for all the Prizes exceeding ₹ 10,000/-
whether in a single ticket or in aggregate to the Director, Kerela, State Lotteries/Nodal Officer.

2. If the claim of any winner for prize money exceeding ₹ 10,000/- whether in a single ticket or in aggregate value is
presented before the Distributor vide this claim form or its distribution network (Including Sub Distributor, Area
Distributor, Stockists, Sub Stockists, Agents & Retailers), they should advice the claimant to submit the same to the
office of Nodal Officer/The Director, Kerela State Lotteries.

3. The Name of the claimant, Postal Address, Contact Number, Details of the Winning Ticket should be visibly clear
along with Pan Card, Aadhar Card, Details of the Bank along with a cancelled cheque shall be enclosed with the
Application form.

4. The Original ticket shall be enclosed with 3 passport size photos & photocopy of the documents duly attested by a
First-Class Magistrate/ Notary Public along with an affidavit swearing the ownership of the winning ticket.

5. The Government through its Director / Nodal Officer shall not be responsible/ liable to pay for tickets lost in transit,
defaced, laminated or mutilated.

6. Forged, fabricated, tampered, duplicated, altered, color copy or printed outside the designated security printing press,
Tickets purchased from any middlemen/ broker/ theft or any other illegal manner, action shall be taken as per the court
of law and the person shall be available before the appropriate authority as and when called for.

7. The Director shall disburse the Prize Money after proper verification of genuineness of the Lottery Ticket(s) and
deduction of all taxes liable.

8. The Prize money shall only be paid in the form of RTGS/ Demand Draft etc., after deducting the necessary
commission/ charges as applicable.

9. Claimants within the State of Kerela shall get the claim from the Directorate of Kerela State Lotteries and such
payments shall be released after producing of all necessary documents as prescribed in the application form.

10. The Directorate of State Lotteries through its authorized Distributors or Representatives shall publish the details of
the prize winners in all types of media as a tool for marketing the lotteries of the State only after the acceptance by
the concerned prize winner.

11. All claims shall be submitted with complete application form and supporting documents to the Directorate/ Nodal
Officer within 30 days from the date of draw published in its official gazattee for further process.

Issued by the Director, Nagaland State Lotteries, Government of Kerela

Page 2 of 2
(On ₹2000/- Stamp Paper / E- Stamp. Paper)

TO WHOM IT MAY CONCERN

DECLARATION
This is to certify and affirm that the Prize Winning Lottery Ticket submitted along
with the Application for Lottery Prize Claim herewith and the details of which are
set forth herein below are original and genuine Prize Winning Lottery Ticket
physically purchased by me.
Prize Winning Ticket No.
Draw Date
Draw No.
Lottery Name
Place of Purchase
Name of Claimant

Address of Claimant

Mobile No. of Claimant

That I hereby declare and affirm that if the above-mentioned Prize Winning
Lottery Ticket submitted by me is found to be fabricated, tampered, duplicate,
altered, colour photocopy, printed anywhere apart from the assigned security
printers, purchased from any broker/middlemen/agent, obtained from the
original winner by way of coercion/theft or any other method or found to be
illegal in any manner then the concerned Authority shall be at liberty to take
appropriate legal action against me by any means and can initiate Civil and
Criminal proceedings against me.
I further declare that I shall be available for personal deposition, if the
Government of Kerela enquires on the doubt of genuineness of my Prize Claim
or Place of Purchase.

Revenue
Recent
Passport Stamp
Size
Photograph

Photograph of Claimant Signature of Claimant