CLAIM FORM

PHOTO

DIRECTORATE OF PUNJAB STATE LOTTERIES
CHANDIGARH APPLICATION FOR CLAIMING THE
PRIZE MONEY OF PUNJAB STATE__________________-

(See instructions given below before filling the
Form)

Affix your photo duly attested
indicating the name on the front
of photograph.

1. Name of Prize Winners(s)(in block letters)_______________________________
2. Minor/Major

_______________________________________________

3. S/o ,D/o ,W/o

_______________________________________________

4. Permanent Address

_______________________________________________
_______________________________________________
_______________________________________________

5. Present Address with telephone no. , if any _____________________________
_____________________________
6. Occupation

_______________________________________________

7. Are you a citizen of India
8. Citizenship

_________________________________________

_______________________________________________

9. Complete address of Income Tax Circle
10. Prize Winning Ticket No.

_____________________________

_________________________________________

11. Date of Draw

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12. Amount of Prize

_______________________________________________

Date:

Signature of Applicant

ADVANCE RECEIPT
Received a sum of Rs.___________(Rupees)___________________________________
from the Director ,Punjab State Lotteries, Chandigarh being the Prize amount won by
Ticket No.____________________ of Punjab State ___________________________
whose draw was held on _____________
Full Postal Address
Revenue Stamp & Signature