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Hoosier Lottery Claim Form 2013-2020

TICKET FOR YOUR RECORDS. • PROVIDE A COPY OF A GOVERNMENT ISSUED PICTURE I.D. For your protection, we suggest you mail your claim by certified mail. FOR LOTTERY USE ONLY CIRCLE ONE: DRAW GAME 1.TICKET NO. OR CASHIER’S INITIALS CHECK NO. STAPLE TICKET TO TOP COPY HERE PLEASE DO NOT STAPLE THROUGH ANY NUMBERS OR PLAY SPOTS ON TICKET! INSTANT GAME 2. DRAW DATE 5. PRIZE AMOUNT 7. NAME LAST NAME – PLEASE PRINT (MM-DD-YY) 4. GAME TYPE 3. VALIDATION NO. .00 .00 6. WAGER AMOUNT FIRST.

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