Lottery Prize Claim Declaration Form (Group)

Lottery Prize Claim Declaration Form (Group)
For Prizes of $1,000 or more
RESET
For Prize Centre purposes only
Customer reference number
ID type (do not record the ID number)
Date of claim (yyyy/mm/dd)
Claimant Information
Legal Name (as shown on government issued ID):
First name
Middle name
Home address – Street number, street name, unit/apt. number, RR# or PO Box #
Date of birth (yyyy/mm/dd)
Home telephone number
Mobile number
Last name
City
Province
Postal code
Email address
Ticket Information
Game name
Ticket number
Prize amount
Notice of Collection of Information
The personal information provided on this form is collected under the authority of the Ontario Lottery and Gaming Corporation Act, 1999 and
Regulation 198/00, s. 10 and 11. This information is intended to be used for the following principal purposes, and for any further purposes
reasonably necessary to give effect to these purposes: (1) investigating and validating the prize claim; (2) sharing the information with third
parties, including the Alcohol and Gaming Commission of Ontario and police services, for such investigation and validation purposes; (3)
monitoring and enforcing compliance with OLG’s Lottery Prize Claim Policies and Procedures; (4) publishing the personal information as
described in this Declaration Form; (5) assisting OLG in managing its lottery games and in maintaining the integrity thereof; and (6) complying
with legal requirements. Where photocopies of certain identification (e.g. driver's licence) are required to submit to OLG for age and residency
verification and/or for identification purposes, this information will be securely destroyed after verification takes place. By submitting this type
of identification, you consent to the destruction thereafter. You may visit olg.ca or speak to a Customer Service Representative for more
information on the collection of this information and our Privacy Policy by calling toll-free at 1-800-387-0098.
Section A – Declaration
In consideration of and to induce Ontario Lottery and Gaming Corporation (OLG) to deliver the Prize, as referred to above, to me
as a Group member (the undersigned Claimant), I hereby declare that:
Select
Yes or No.
1. The persons listed on the Lottery Prize Claim Group List are the only persons having any interest in the Ticket referred to
above, which has been presented for the Prize.
Yes
No
2. Does any other person(s) other than those listed on the Lottery Prize Claim Group List have any right, interest or claim in or to
the Ticket?
Yes
No
3. I obtained the Ticket as a member of a group purchase.
Yes
No
4. My Group came into possession of the Ticket in a lawful and legitimate manner and in accordance with the rules and
regulations governing the purchase and issuance of the Ticket. These rules and regulations are available upon request to OLG,
and are also available on the OLG website at www.olg.ca.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
5. My Group purchased the Ticket from a lottery retailer.
If yes, name and/or location of lottery retailer (provide both, if known). If retailer name or location is not known, please explain.
If no, please provide the name of the person(s) who purchased the Ticket and an explanation of how your Group received it.
Purchaser name
Phone number
Explanation
Section B – Identification of Insider and Related Parties
6. Within 12 months of the date of this prize claim, I am or have been:
a) a person required to be registered under the Gaming Control Act, 1992. Persons required to be registered (“Registrant”)
include (A) lottery equipment suppliers, lottery retailer managers, or lottery retailers, in accordance with Regulation 281/07
(Lotteries); and (B) operators, sellers, gaming-related suppliers, non-gaming related suppliers, trade unions, category 1
gaming assistants, and category 2 gaming assistants, in accordance with Regulation 78/12 (General).
If yes, name of Registrant:
b) a director, officer, partner, sole proprietor or employee of a Registrant (as described above), and who is involved in the sale,
redemption, distribution or manufacturing of lottery products, equipment or services.
If yes, name of Registrant:
c) a person who is acting on behalf of a Registrant (as described above), and who is involved in the sale, redemption,
distribution or manufacturing of lottery products, equipment or services.
If yes, name of Registrant:
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LT-PZ026 (02/14)
Section B – Identification of Insider (continued)
d1) a member of OLG’s Board of Directors;
Yes
No
Yes
No
a person directly on OLG’s payroll;
Yes
No
an Employee of OLG on paid or unpaid leave.
Yes
No
d2) a director, officer or employee of Alcohol and Gaming Commission of Ontario (AGCO)
Yes
No
e) an individual consultant or public sector employee retained by OLG through contracts of retainer for periods of 30
calendar days or more in the aggregate.
Yes
No
Interprovincial Lottery Corporation (ILC);
Yes
No
a Canadian provincial government lottery agency or corporation (other than OLG).
Yes
No
Yes
No
Yes
No
Ministry of Finance;
Yes
No
Ministry of the Attorney General;
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
a full-time, part-time or student employee of OLG;
f) a director, officer, or employee of:
g) a member of the Ontario Provincial Police (OPP) assigned to the OPP’s AGCO Investigation and Enforcement Bureau.
h) a director, officer, partner, sole proprietor or employee of a supplier to OLG of independent audit, advisory or security
services.
If yes, name of supplier:
i)
j)
an employee of an accountable Ontario Government Ministry of OLG or AGCO:
an immediate family member meaning a married spouse, common-law spouse, child, parent or sibling of a person
described in Section B 6a), b), c), d), e), f), g), h) or i) above (whether living in the same residence or not), but excluding
in-laws and step-family members.
If yes, provide details of the relationship including the name of the person(s) and their place of work.
k) a relative (meaning a person other than an immediate family member) who is connected by blood or marriage and who
resides with a person described in Section B 6a), b), c), d), e), f), g), h) or i) above, and includes in-laws and step-family
members.
If yes, provide details of the relationship including the name of the person(s) and their place of work.
l)
an executive (e.g. President, Vice-President) of the union that represents the employees at the retail store where the Ticket
was purchased.
If yes, provide the name of the union and your title.
m) involved in the repair or maintenance of OLG lottery equipment (including terminals and ticket checkers) at the retail
store where the Ticket was purchased.
Section C – Acknowledgements
This document shall be binding upon the heirs, executors, administrators and assigns of myself and shall enure to the
benefit of OLG and ILC and their respective successors, assigns, affiliates, officers, directors, employees and agents.
I acknowledge
To the best of my knowledge, the information contained in this document is accurate.
I acknowledge
For prizes of $1,000 or more, it is OLG's practice to publish the winner's name, town/city, prize amount, game name, game number (INSTANT) or draw
date (online) and "Insider" status (if any) on OLG's website (olg.ca) for a period of 30 calendar days from the date of the prize payment. For purposes of
the Declaration Form, an "Insider" is an individual whom OLG reasonably believes meets any of the criteria identified in Section B of this Declaration Form.
For major prizes of $10,000 or more, OLG shall have the right to publish in any medium, the winner's name, town/city, prize amount, game name, game
number (INSTANT) or draw date (online) and a current photograph of the winner. If the claimant has answered yes to any parts of Sections B above, or if
OLG reasonably believes that the claimant meets any of the criteria of Section B above, it is OLG's practice to hold payment for 30 calendar days after a
tentative decision to pay the claimant has been made and during this time, publish the claimant's name, town/city, prize amount, game name, game
number (INSTANT) or draw date (online) and Insider status to allow any person(s) to dispute the prize claim.
An individual who met any of the criteria identified in Section B(5) d) and e) above at the time that the individual purchased the Ticket, received the Ticket
as a gift, or otherwise acquired an interest in the Ticket is considered a “related party” and is not eligible to participate in a lottery and is not entitled to
claim a prize in a lottery.
And also in consideration of and to induce OLG to deliver the Prize to me, I agree that I will not make a claim against OLG for broadcasting, printing,
royalty or other rights and shall have no claim against OLG for infringement of privacy rights, infringement of copyright, or otherwise by reason of the
publication or broadcasting of my name, town/city, prize amount, game name, game number (INSTANT), draw date (online), my photograph, or Insider
status (if any).
IN WITNESS WHEREOF, I have signed this document at the town/city of
in the province of
, on the
,
, 20
day of
.
SIGNED in the presence of:
Witness name
Witness signature
)
)
)
)
Claimant name
Claimant signature
For more information, including how to claim merchandise prizes, call the OLG Support Centre at 1-800-387-0098 or visit olg.ca.
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LT-PZ026 (02/14)