Directorate of Small Savings & Lotteries, Goa
CLAIM APPLICATION FOR PRIZE OF THE GOA STATE LOTTERIES
FORM - 1
PLEASE FILL IN THE FORM IN ENGLISH ONLY AND IN CAPITAL LETTERS
PLEASE READ INSTRUCTIONS OVERLEAF BEFORE SUBMITTING THE FORM
To,
Paste
Passport Size Photograph Here
The Director,
Directorate of Small Savings & Lotteries,
Government of Goa,
Serra Building, Altinho, Panaji-Goa. 403 001
SUB.: Claim application for Prize of the Goa State Lotteries.
CLAIMENT DETAILS:
Full Name of the Prize Winner : _____________________________
Mailing Address : _____________________________
_____________________________
_____________________________
Father’s/Husband’s Name : _____________________________
Date of Birth : _____________________________
Profession / Nature of Business : _____________________________
Name of the Organization : _____________________________
PAN (If any) : _____________________________
Name of Bank : _____________________________
Address of Bank : _____________________________
_____________________________
Bank Account No. : _____________________________
WINNING TICKET DETAIL:
Winning ticket transaction No. : ______________ Draw No. ______
Date of Draw : ______________ Time: _________
Winning Numbers : _____________________________
Name of Lottery : _____________________________
Rank of Prize : ________ Prize Amount _________
Name of Retailer (Point of sale) : _____________________________
Retailer code : _____________________________
Encl.:
1. Original Prize Winning Ticket.
2. Proof of date of Birth.
3. Proof of address.
4. PAN card photo copy. 5. 4 Passport size photographs & Affidavit duly attested by Notary (On Rs.20/- Stamp Paper.

INSTRUCTIONS
CLAIM FORM FOR PRIZE OF THE GOA STATE LOTTERIES
1. Write your name address and signature on the back of the ticket. Complete the claim form as per the instructions provided. Indicate the prize amount legibly.
2. The winning ticket and claim form must be completed in the name of one individual or legal entity.
3. Prize amount up to Rupees Five Thousand (5000/-) shall be paid by the Retailer.
Prize amount above Rupees Five Thousand (5000/-) shall be paid directly by the Director State Lotteries, Government of Goa. The prize amount shall be claimed by submitting a claim form along with 4 passport size photographs duly attested by a first class magistrate / notary. The claim needs to be sent to the Goa Government directly by registered post at claimant’s own risk. Payment will be made after deducting the tax as applicable on the date.
4. Prize will be given only on complete physical verification of the documents, tickets and proof of identity.
5. Incomplete forms shall be considered invalid.
6. Government of Goa is not responsible for any non-delivery of mails, loss in transit or non-receipt of forms dispatched by the claimant.
7. The prize amount will be paid directly by the Government of Goa and sent to the address mentioned in the claim form. Such payment will be subject to Tax deduction at source.
8. Government or Marketing Agents / Distributors is entitled to use the winner’s name, photograph and other information for promotional and / or publicity purposes and the claimant agrees to the same without any further claim for payment.
9. Any dispute regarding the payment of prize shall be subject to exclusive jurisdiction of the courts in Goa only.
10. Prize should be claimed within 60 days from its declaration.
11. Government of Goa may advise you to submit more information over and above mentioned in the claim form.
______________
Signature
Received with thanks from, The Director, Goa State Lotteries, Panaji Rs.___________ (Rupees
___________________________________ only) towards my claim of ticket transaction No.
___________________ of _________________ Lottery Draw No. __________ held on
_______________________.
Name : ________________________________
Revenue
stamp
Address : ________________________________
________________________________
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