Lottery Claim Form PDF Details

We've all dreamed of what we'd do if we won the lottery, and while most of us never actually get to experience these fantasies, there are those lucky few who get to make them a reality. If you're one of the fortunate individuals who find yourself holding a winning ticket, it's important to know how to submit your claim form correctly in order to receive your winnings. In this blog post, we'll be discussing the process for submitting your lottery claim forms as well as some tips on avoiding common mistakes that could delay or even disqualify your winnings!

Form NameLottery Claim Form
Form Length5 pages
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesmolottery, missouri lottery po, mo lottery, mo lottery claim form

Form Preview Example


Missouri Lottery WINNER CLAIM FORM

Oficial Missouri Lottery Claim Form

Awinning Missouri Lottery ticket worth $600 or less can be cashed at a licensed Lottery retailer selling that game, regardless of where the ticket was purchased and provided the cash is available.PLEASE PRINT your name, address and phone number on the back of your ticket - YOU MUST SIGN YOUR TICKET. Any

Badvised that items 1, 2, 3, 4, 5, 6, 7, 8, 11, and 12 are subject to being disclosed pursuant to a request under Chapter 610, Missouri Revised Statutes.COMPLETE ITEMS 1-17 BELOW. Please use this form to claim INSTANT (Scratchers) or DRAW GAME prizes. You are hereby

Cticket to the top right corner of this form. Mail this form and the winning ticket to: MISSOURI LOTTERY, PO BOX 7777, JEFFERSON CITY, MO 65102-7777, OR hand deliver your ticket and completed claim form to any Missouri Lottery ofice.RETAIN A PHOTOCOPY of the front and back of your winning ticket and of this completed form for your personal records. Staple the


Last Name


2. First Name


3. M.I. 4. Date of Birth








































































Mailing Address [Street, Route or PO Box#]




6. City












































8. Zip Code

9. SSN# / FIN#

10. Phone

11. U.S. Resident

12. Amount of Prize [before taxes]

$ .00

[area code]

13.Number of people claiming prize

Y or N

14.If more than one claimant: Is this prize to be paid equally?

15.If not equally, enter

Y or N

dollar amount you


are claiming


16.Are you an employee of, related by blood or marriage to, or an owner/partial owner of a business that sells Missouri Lottery tickets?



If “Yes,” you must state the business name

and address



17.Under penalty of perjury, I declare that the name, address and Social Security number, which I have furnished, correctly identiies me as the recipient of the prize claimed, that the ticket attached to this form has not been falsely made, altered, forged or counterfeited and all information set out above is correct.

Claimant’s Signature:






In addition to the claim form, it is your responsibilty to complete IRS Form W-9 - Request for Taxpayer Identiication Number and Certiication for any taxable winnings over $600.

Form W- 9

(Rev. January 2003)

Department of the Treasury Internal Revenue Service

Request for Taxpayer

Identification Number and Certification

Give form to the requester. Do not send to the IRS.

Print or type See Specific Instructions on page 2.


Business name, if different from above

Check appropriate box:












Exempt from backup


Sole proprietor
























Address (number, street, and apt. or suite no.)







Requester’s name and address (optional)

City, state, and ZIP code

List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN).

However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on

page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note: If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.

Social security number


Employer identification number

Part II Certification

Under penalties of perjury, I certify that:

1.The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

2.I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

3.I am a U.S. person (including a U.S. resident alien).

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN. (See the instructions on page 4.)

Sign Here

Signature of

U.S. person


Purpose of Form

A person who is required to file an information return with the IRS, must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA.

U.S. person. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to:

1.Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

2.Certify that you are not subject to backup withholding,


3.Claim exemption from backup withholding if you are a U.S. exempt payee.

Note: If a requester gives you a for m other than For m W-9 to request your TIN, you must use the requester’s for m if it is substantially similar to this For m W-9.

Foreign person. If you are a foreign person, use the appropriate Form W-8 (see Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities).

Nonresident alien who becomes a resident alien.

Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the recipient has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement that specifies the following five items:

1.The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.

2.The treaty article addressing the income.

3.The article number (or location) in the tax treaty that contains the saving clause and its exceptions.

4.The type and amount of income that qualifies for the exemption from tax.

5.Sufficient facts to justify the exemption from tax under the terms of the treaty article.

Cat. No. 10231X

Form W- 9 (Rev. 1-2003)

Form W-9 (Rev. 1-2003)

Page 2

Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.

If you are a nonresident alien or a foreign entity not subject to backup withholding, give the requester the appropriate completed Form W-8.

What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 30% of such payments (29% after December 31, 2003; 28% after December 31, 2005). This is called

backup withholding.” Payments that may be subject to backup withholding include interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return.

Payments you receive will be subject to backup withholding if:

1.You do not furnish your TIN to the requester, or

2.You do not certify your TIN when required (see the Part II instructions on page 4 for details), or

3.The IRS tells the requester that you furnished an incorrect TIN, or

4.The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or

5.You do not certify to the requester that you are not

subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup withholding. See the instructions below and the separate

Instructions for the Requester of Form W- 9.


Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.

Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.

Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

Misuse of TINs. If the requester discloses or uses TINs in violation of Federal law, the requester may be subject to civil and criminal penalties.

Specific Instructions


If you are an individual, you must generally enter the name shown on your social security card. However, if you have changed your last name, for instance, due to marriage without informing the Social Security Administration of the name change, enter your first name, the last name shown on your social security card, and your new last name.

If the account is in joint names, list first, and then circle, the name of the person or entity whose number you entered in Part I of the form.

Sole proprietor. Enter your individual name as shown on your social security card on the “ Name” line. You may enter your business, trade, or “doing business as (DBA)” name on the “ Business name” line.

Limited liability company (LLC). If you are a single-member LLC (including a foreign LLC with a domestic owner) that is disregarded as an entity separate from its owner under Treasury regulations section 301.7701-3, enter the owner’s name on the “Name” line. Enter the LLC’s name on the

“ Business name” line.

Other entities. Enter your business name as shown on required Federal tax documents on the “ Name” line. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on the “ Business name” line.

Note: You are requested to check the appropr iate box for your status (individual/sole propr ietor, corporation, etc. ).

Exempt From Backup Withholding

If you are exempt, enter your name as described above and check the appropriate box for your status, then check the

Exempt from backup withholding” box in the line following the business name, sign and date the form.

Generally, individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends.

Note: If you are exempt from backup withholding, you should still complete this for m to avoid possible erroneous backup withholding.

Exempt payees. Backup withholding is not required on any payments made to the following payees:

1.An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2);

2.The United States or any of its agencies or instrumentalities;

3.A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities;

4.A foreign government or any of its political subdivisions, agencies, or instrumentalities; or

5.An international organization or any of its agencies or instrumentalities.

Other payees that may be exempt from backup withholding include:

6.A corporation;

7.A foreign central bank of issue;

8.A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States;

Form W-9 (Rev. 1-2003)

Page 3

9.A futures commission merchant registered with the Commodity Futures Trading Commission;

10.A real estate investment trust;

11.An entity registered at all times during the tax year under the Investment Company Act of 1940;

12.A common trust fund operated by a bank under section 584(a);

13.A financial institution;

14.A middleman known in the investment community as a nominee or custodian; or

15.A trust exempt from tax under section 664 or described in section 4947.

The chart below shows types of payments that may be exempt from backup withholding. The chart applies to the exempt recipients listed above, 1 through 15.

If the payment is for . . .

THEN the payment is exempt


for . . .



Interest and dividend payments

All exempt recipients except


for 9



Broker transactions

Exempt recipients 1 through 13.


Also, a person registered under


the Investment Advisers Act of


1940 who regularly acts as a





Barter exchange transactions

Exempt recipients 1 through 5

and patronage dividends




Payments over $600 required

Generally, exempt recipients

to be reported and direct

1 through 7 2

sales over $5,000 1




1See Form 1099- MISC, Miscellaneous Income, and its instructions.

2However, the following payments made to a corporation (including gross proceeds paid to an attorney under section 6045(f), even if the attorney is a corporation) and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys’ fees; and payments for services paid by a Federal executive agency.

Part I. Taxpayer Identification

Number (TIN)

Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN.

If you are a single-owner LLC that is disregarded as an entity separate from its owner (see Limited liability company (LLC) on page 2), enter your SSN (or EIN, if you have one). If the LLC is a corporation, partnership, etc., enter the entity’s EIN.

Note: See the chart on page 4 for further clar ification of name and TIN combinations.

How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local Social Security Administration office or get this form on-line at online/ ss5.html. You may also get this form by calling 1-800-772-1213. Use Form W- 7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS- 4, Application for Employer Identification Number, to apply for an EIN. You can get Forms W-7 and SS-4 from the IRS by calling 1-800-TAX-FORM

(1-800-829-3676) or from the IRS Web Site at

If you are asked to complete Form W-9 but do not have a TIN, write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.

Note: Wr iting “ Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.

Caution: A disregarded domestic entity that has a foreign owner must use the appropr iate For m W-8.

Form W-9 (Rev. 1-2003)

Page 4

Part II. Certification

To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if items 1, 3, and 5 below indicate otherwise.

For a joint account, only the person whose TIN is shown in Part I should sign (when required). Exempt recipients, see Exempt from backup withholding on page 2.

Signature requirements. Complete the certification as indicated in 1 through 5 below.

1.Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification.

2.Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form.

3.Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.

4.Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN.

Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).

5.Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA or Archer MSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.

What Name and Number To Give the Requester

For this type of account:

Give name and SSN of:

1. Individual

The individual

2. Two or more individuals (joint

The actual owner of the account



or, if combined funds, the first



individual on the account 1

3. Custodian account of a minor

The minor 2


(Uniform Gift to Minors Act)


4. a. The usual revocable

The grantor-trustee 1


savings trust (grantor is



also trustee)



b. So-called trust account

The actual owner 1


that is not a legal or valid



trust under state law


5. Sole proprietorship or

The owner 3


single-owner LLC


For this type of account:

Give name and EIN of:





Sole proprietorship or

The owner 3


single-owner LLC



A valid trust, estate, or

Legal entity 4


pension trust



Corporate or LLC electing

The corporation


corporate status on Form






Association, club, religious,

The organization


charitable, educational, or



other tax-exempt organization



Partnership or multi-member

The partnership





A broker or registered

The broker or nominee





Account with the Department

The public entity


of Agriculture in the name of



a public entity (such as a



state or local government,



school district, or prison) that



receives agricultural program








1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished.

2 Circle the minor’s name and furnish the minor’s SSN.

3 You must show your individual name, but you may also enter your business or “ DBA” name. You may use either your SSN or EIN (if you have one).

4 List first and circle the name of the legal trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.)

Note: If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA or Archer MSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, or to Federal and state agencies to enforce Federal nontax criminal laws and to combat terrorism.

You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 30% of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.

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Filling out segment 2 of missouri lottery claim form

3. Within this step, take a look at Department of the Treasury, Name, Business name if different from, Check appropriate box, Individual Sole proprietor, Address number street and apt or, City state and ZIP code, List account numbers here optional, e p y t r o, t n i r P, e g a p, n o, s n o i t c u r t s n, c i f i c e p S e e S, and Corporation. All of these have to be taken care of with utmost precision.

Name, n o, and Address number street and apt or in missouri lottery claim form

Many people generally make errors when filling out Name in this part. Don't forget to read twice what you enter right here.

4. Filling out Certification instructions You, Sign Here, Signature of US person, Purpose of Form A person who is, Certify that the TIN you are, waiting for a number to be issued, Certify that you are not subject, Claim exemption from backup, US exempt payee, Note If a requester gives you a, Date, Nonresident alien who becomes a, If you are a US resident alien who, exception contained in the saving, and The treaty country Generally this is essential in this form section - be certain to be patient and fill in each and every field!

Certify that you are not subject, Claim exemption from backup, and Signature of US person of missouri lottery claim form

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