Directorate of Small Savings & Lotteries, Goa
FORMAT OF AFFIDAVIT TO BE SUBMITTED BY WINNERS (DULY ATTESTED BY NOTARY PUBLIC) ALONG WITH RESPECTIVE CLAIM FORMS
Affidavit

I, ……………..……….., aged about ….. years, son / daughter of Shri. ………………… resident of ……………………………………... …………………………………………………………………. …….. do hereby solemnly affirm and declare as follows:
1. That I am a bonafide citizen of India by birth.
2. That I am the Sole Owner of Prize Winning Ticket No. ……………….. of _______________ Online Lottery of Draw No. ……………. Dated ………… of the ………(prize rank) Prize of Rs. …………….
3. That I will not claim the other prize or whatever I am not entitled to.
4. That I am the bonafide / genuine claimant of the …… Prize of ____________ online lottery.
5. That there are no other claimant / winner of the Prize Winning Ticket No. ……………. of draw dated …………………. of ____________ online Lottery.
6. That the above facts are true to the best of my knowledge and belief.
Dated the ________________ day of _________________.
DEPONENT
Verified, affirmed and signed before me at _____________ on ______________.