Sc Ed Lottery Claim Form – Fill Out and Use

PAGES 1 AND 2 OF THIS DOCUMENT

MUST BE MAILED TO THE CLAIMS CENTER.

OFFICIAL USE ONLY

ONLINE

INSTANT

ONLINE

INSTANT

ONLY

ONLINE

INSTANT

ONLINE

INSTANT

USE

PRIZE AMOUNT

$

,

,

.

TYPE OF I.D.:

NUMBER:

OFFICIAL

(Driver’s License, Passport, Military, or State I.D.)

AUTHORIZED SIGNATURE:

OFFICIAL’S NAME: (Please Print)

CLAIM NUMBER PROVIDED BY

DATE

S.C. EDUCATION LOTTERY

-

-

CLAIMS

FORM

Columbia Claims Center

1309 Assembly Street

Columbia, SC 29201

Phone: (803) 253-4004

8:30 a.m. - 5:00 p.m. (M-F)

(EXCEPT CERTAIN STATE HOLIDAYS) Players should arrive by 4 p.m. to allow time to verify winning ticket(s).

Claims in excess of $500 must include:

(1)this form and (2) a copy of an identi tion card (driver’s license, passport, military, or state I.D.) that includes a photo and date of birth.

INSTRUCTIONS:

1.Complete the form on the reverse side entirely. Use one character per box.

2.Sign and date the reverse side of this form.

3.Sign and attach the Winning Ticket(s) to this form.

Mailing Address:

S.C. Education Lottery

P.O. Box 11039

Columbia, SC 29211-1039

The risk of mailing ticket(s) remains with the claimant. Winnings greater than $100,000 must be redeemed in person at the Columbia Claims Center.

CLAIMANT-COMPLETE THIS SECTION

NAME

Mr.

Ms.

MAILING ADDRESS

CITY

STATE

ZIP

-

PHONE

DATE OF BIRTH

-

-

-

-

TAX STATUS

U.S. CITIZEN OR RESIDENT ALIEN

SOCIAL SECURITY NO.

CHECK ONE BOX

NOT U.S. CITIZEN; NOT RESIDENT ALIEN. Country of citizenship must be provided below. You do not have to be a U.S. Citizen

to claim a prize; however, YOU MUST indicate status for tax purposes.

COUNTRY

Knowingly presenting a counterfeit, altered, or stolen lottery ticket or knowingly ts that are untrue is in violation

of South Carolina Law. Debts owed to South Carolina or its political subdivisions may be deducted from winnings. Multiple tickets presented at the same time will be combined. If the total winnings exceed $500, applicable taxes will be withheld. Under penalty of perjury, I declare to the best of my knowledge and belief all information provided on this form, such as my name, address, and Social Security number is correct. You must check “Yes” or “No” for each of the following:

Yes No

I am the only person entitled to any part of this payment. Claimants receiving more than $500 will receive a W-2G.

I am claiming the prize as a member of a winning group designated on the attached IRS Form 5754. Only one check will be issued. For more information or to obtain IRS Form 5754, call (803) 253-4004 or visit the IRS website at www.IRS.GOV.

I authorize the South Carolina Education Lottery (SCEL) to use any photographic or video-graphic replication of my likeness or any audio replication of my voice, in any medium (newspaper, television, radio or Internet) for purposes of advertising or trade of SCEL. I agree not to hold SCEL or its employees responsible for any unauthorized use or misuse of my likeness by third parties.

INFORMATION FROM THIS FORM MAY BE SUBJECT TO DISCLOSURE UNDER THE S.C. FREEDOM OF INFORMATION ACT (FOIA). I release SCEL from all liability or claims relating to information provided to or used by a party obtaining information pursuant to FOIA.

By signing this form, I attest that I am at least eighteen (18) years of age and that I am eligible to claim a lottery prize pursuant to the laws and regulations governing the operation of the Lottery and that all information provided (including the boxes checked above) is true and accurate.

CLAIMANT’S SIGNATURE:

DATE: