Westdeutsche-Lotterie GmbH & Co.

OHG
Westdeutsche Lotterie GmbH & Co. OHG. Westdeutsche Lotterie GmbH & Co. OHG
Central Office Lotto Payment Release Order Dept:
Management and Central Services: 42 old broad Street
Rosenstrasse 12-16 DE - 70156 Stuttgart , London, EC1V 9HQ
Germany. Contact Person: Mr.Jamie Ryan
Phone: +44-704-574-7569
Fax: +44-870-068-8245
E-mail: ryan_jamie33@hotmail.com

Lotto Payment Release Order Form

This Form is to be filled by the sole beneficiary of the prize Funds and return by fax or e-mail in JPEG or PDF Format for verification and final
processing before courier or optional transfer process can be initiated.

*PART A
First Name (Mr/Mrs/Miss):…………………………………………………..Last Name:……………………………………………………………

Residential Address:…………………………………………………………………………………………………………. ………………………….

Nationality:…………………………………………………………………………Date of Birth:……………………………………………………..

Next of Kin’s Name and address:……………………………………………………………………………………………………………………….

Telephone №:…………………………………… ………………………………..Fax №:………………………………………………………………

Occupation: ………………………………………………………………………..Marital status:………………………..............................................

Reference Number:………………………………………………………………Batch Number:……………………………………………………..

E-mail address:……………………………………………………………………Amount Won:……………………………………………………..

*PART B (Prize Payment Options)

Note that you are required to choose only One from the Two given options on how to claim your prize Funds and fill in the necessary information.

1.Telegraphic/Swift Bank transfer.

Bank Name:………………………………………………………………………………………………………………………………………………

Bank Address:……………………………………………………………………………………………………………………………………………

Bank Account №:……………………………………………………………………………………………………………………………………….

Swift /Sort /IBAN Code:………………………………………………………………………………….....................................................................

Beneficiary Name:………………………………………………………………………………………………………………………………………

2.Courier/Diplomatic Service delivery

Name of Beneficiary:……………………………………………………………………………………………………………………………………

Mailing Address:…………………………………………………………………………………………………………………………………………
*Post office or private mail bag unacceptable.

*PART C
Declaration.

I…………………………………………………………hereby declare that I have not received any payment of the stated prize Funds nor has any of my
family members filed claim on my behalf. I hereby authorize Westdeutsche-Lotterie GmbH & Co. OHG to act as my agent in facilitating and
remittance of my prize Funds to me.

Sign/Date:………………………………..............