FORM OF APPLICTION CLAIMING PRIZE OF THE LOTTERY 1. Date of Application 2. Name of Claimant (in capital letters) 3. Full postal address of the claimant with pin code (in capital letters) 4. Profession of claimant 5. Name of Lottery Scheme. 6. Draw No. and date 7. Ticket No. and Series 8. Category of prize 9. Amount of prize 10. Exercise of options (if any). 11. If the payment of Prize is sought in shape of Demand Draftname of the nearest Branch of State Bank of India or its subsidiary Bank where it shall be encashable shall be furnished. 12. The following are enclosed (i) Prize Winning tickets duly signed by the claimant. (ii) Three copies of passport size photographs of claimant duly attested by Government Gazetted Officer/Bank Manager. I solemnly affirm and under take as under: (i) that I have not won any other lottery prize of Goa State or any other State during the financial year 20 -20 . (ii) that I hereby agree and undertake to pay additional Income Tax/Surcharge if any required under the Rules. (iii) I have not made any claim for this prize previously. (Signature of Claimant) Received this day the .....of ..........20 the sum of Rs.........(Rupees ..................only) being the amount payable on account of the above claim. Revenue Stamp Signature of claimant FOR USE IN PAYING OFFICE 1. The above listed tickets have been verified from the list of prize winning numbers. 2. Passed for payment of Rs. ...(Rupees............. only) after deducting Income Tax @ ...% from the prize amount . 1st verified by 2nd verified by ...... ..... ..... Signature Signature Office-in-Charge of Accounts Paid vide cheque No........ Date ...... Counter signed by:
