GOVERNMENT OF NAGALAND DIRECTORATE OF STATE LOTTERIES KOHIMA :: NAGALAND APPLICATION FOR LOTTERY PRIZE CLAIM PRIZE WINNING TICKET No: PASTE Lottery : YOUR RECENT PASSPORT Draw No : Held on : SIZE PHOTOGRAPH To ALONG WITH SIGN

The Director / Nodal Officer, Directorate of Nagaland State Lotteries, 121,Jessore Road South Michael Nagar, Madhyam Gram, Near National Model High School, Kolkata – 700133 , West Bengal

I HEREWITH SUBMIT MY PRIZE WINNING TICKET FOR YOUR KIND CONSIDERATION.

Full Name of the Prize winner : Address :

Father’s / Husband’s Name : Profession : Name of the Organisation : Nature of Business : Rank of the Prize : Prize Amount : PAN Number : Contact Number : Bank Account Number : IFSC Code : Name of the Bank & Branch :

I enclose herewith the original ticket after signing and indicating my address on its reverse side. I further enclose an Affidavit, Pan Card, one ID proof, 4 passport sized photographs and a cancelled cheque leaf of my bank account, and I am also aware that the Directorate of State Lotteries can publish my personal details, such as name, address and my photograph in the newspapers, magazine,television,radio,social medias & online websites,outdoor Medias Etc

Signature PRIZE CLAIM INSTRUCTIONS

1. All claims of Taxable Prizes should be submitted to The Director, Nagaland State Lotteries in the prescribed form. 2. The form should be filled clearly showing the Name of the claimant, Postal Address Name of the Lottery, Prize amount, PAN Number, Contact Number and Bank details like Bank Account Number, IFSC code, Name of the Bank and Branch, cancelled Cheque etc. 3. Original prize winning Ticket with one photocopy duly attested by a Gazetted Officer/Notary Public, along with Four passport size photographs of the claimant, an affidavit of ownership of the prize winning ticket from any 1st Class Magistrate/Notary Public should also be submitted. 4. Government of Nagaland shall not be liable to pay prizes on tickets lost in postal transit, defaced or mutilated. 5. Tampered tickets shall not be entitled to any prize and any person claiming prize money with a tampered ticket is liable to be sued in a court of law. 6. The Director shall disburse Prize Money for accepted genuine claims after making necessary deduction of Income Tax etc. 7. Prize money in favour of winners outside Nagaland shall be paid in the form of Demand Draft/RTGS after deducting commission, on drafts and postal charges as applicable. 8. Prize money payable to winners within Nagaland shall be paid in the form of cheque/through RTGS.

9. The Directorate of State Lotteries may publish the details of the Prize Winners which includes the name, address and photo of the winner of a prize amount above `10,000/- in the newspapers, magazine, television, radio, social medias, online websites, outdoor medias etc. the winner who is submitting the original ticket may accept and fill the claim form agreeing to the terms and conditions as stipulated therein

Director, Nagaland State Lotteries Government of Nagaland.