(STAPLE TICKET HERE)

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GOVERNMENT OF SIKKIM ONLINE LOTTERY - WINNER CLAIM FORM
(Please read instructions overleaf)
PLEASE FILL IN WITH CAPITAL LETTERS your name, address and phone number on the back
your ticket- YOU MUST SIGN YOUR TICKET. Any winning Numbers-game ticket of upto
Rs. 10,000/- can be claimed at any licensed numbers-game lottery retailer, regardless of where the
ticket was purchased, provided their cash balances are adequate.
RETAIN A PHOTOCOPY of the front and back of your winning ticket and of this completed form
for your personal records. Staple the ticket to the top right corner of this form and read
instructions overleaf for getting your prize amount.
___________________

1. FIRST NAME

___________________

2. MIDDLE NAME

__________________

3. SURNAME

4.DATE OF BIRTH -________________ 5. GENDER (M/F) -___________

(dd-mm-yy)
6. MAILING ADDRESS
__________________________________________________________________________________
__________________________________________________________________________________
CITY ______________________ STATE ________________ PIN CODE _____________
7. (i) Name of Bank
______________________________
(ii) Name of Branch _______________________________________________
(iii) Branch Code No. ______________________________________________
8. ACCOUNT NO. __________________________
9. PAN NO. (Compulsory) ____________________
10. Contact : (i) Telephone No. __________________
(ii) Mobile No. ____________________
(iii) E-Mail _______________________________________
11. Are you an INDIAN RESIDENT (Y/N) ___________________
12. TICKE T PURCHASED ON ___________________ 13. AMOUNT OF PRIZE ______________
(dd-mm-yy)
14.PROOF OF IDENTITY ATTACHED (Y/N)
PASSPORT COPY/ RATION CARD /VOTERS ID CARD / ANY OTHER _________________________
( Strike out whatever is not applicable)

15.GAME /TICKET INFORMATION Numbers played ______________________

(separate numbers with hyphens)
Ticket FRONT Serial No. ___________________________________________
(Exact no. that appears on the ticket.)
I hereby solemnly declare that I have read the instructions printed overleaf and state that I am over the
age of 18 years and the information supplied above, is true and correct to my knowledge. I undertake to
be liable for any falsity in information provided or misrepresentation made herein and agree to bind
myself to any penalty that Government of Sikkim, in its sole discretion may impose, including
forfeiting the prize claimed and to the liability of offences under Indian law. I further declare that the
ticket has not been falsely made, altered, forged or counterfeited. I agree that by signing this form and
claiming the prize, my name, my locality and prize amount become public information.
Claimant's Signature __________________

Date ________________

FOR OFFICE USE ONLY

Received by :_____________ Date : _______________ Checked by :______________
Date: of forwarding To Treasury department

INSTRUCTIONS
1. Put your name, address and signature on back of the ticket.
2. The winning ticket and claim form must be completed in the name of one individual
or legal entity.
3. Complete the claim form and follow the instructions provided.
4. Indicate the prize amount legibly.
5. You are required t o approach any retailer appointed by PAN India Network Ltd
(Playwin) and get your ticket validated.
6. Prize amount not exceeding Rupees Ten Thousand (Rs.10, 000) shall be paid by the
Retailer.
7. Prize amount above Rupees Ten Thousand (Rs.10, 000/- shall be paid directly by the
Director - Sikkim State Lotteries. The prize amount shall be claimed by submitting a
claim form along wit h 3 passport size photographs duly at tested and supported by an
affidavit sworn in before a first class magistrate in person or through any
scheduled/nationalized bank. The claim ma y be sent to Director, Sikkim State
Lotteries, Gangtok 737101 by registered/ insured post at claimants own risk.
Payment will be made after verification regarding genuineness of the ticket to the
claimant of the ticket, by demand draft/cherub after deducting the tax as applicable
On the date.
8. Prizes will be given only on complete physical verification of the document s, ticket
And proof of identity to the absolute discretion of Government of Sikkim. Decision of
Government of Sikkim shall be final and binding on t he Claimant.
9. Incomplete forms shall be considered invalid.
10. For any assistance required, you may contact any Playwin office.
11. Government of Sikkim/ Playwin is not responsible for any non-delivery of mails, lost
in transit or non-receipt of forms dispatched by the Claimant.
12. Persons/ entities disqualified by law are not eligible to the prize money.
13. Claimant will be responsible to resolve any dispute regarding the claim on prize
money and Government of Sikkim/Playwin shall not bear any responsibility for the
same.
14. The processing of documents received from the Claimant will be done within 90
working days from the receipt thereof.
15. The prize amount will be paid directly by the government of Sikkim and sent t o the
address in the claim form. Such payment will be subject to Tax deduction at source.
16. Playwin is entitled t o use the winner's name, photograph and other information for
promotional and publicity purposes and t he Claimant agrees to the same without any
further claim for payment.
17. Claimant shall not indulge in any press and/or media interviews without the prior
permission from Playwin.
18. Any dispute regarding the payment of prize shall be subject to the exclusive
jurisdiction of the Courts in Gangtok only.
19. Prize should be claimed within 90 days from its declaration.
20. Government of Sikkim or Playwin may advise you to submit more information over
and above mentioned in the claim form.
PAN India Network Ltd:
Mumbai: 135, Continental Building, Dr. A. B. Road, Worli, Mumbai - 400 018,India, Tel: 022-24815671
Kolkata: Flat No. 11,Harrington Mansion,8, Ho Chi Minh Sarani,Kolkata- 700071, Tel:033-22822660/61