CSL 1242 Claim Form

CSL 1242 (R10/22)

Page 1 of 3

FOR DISTRICT OFFICE USE ONLY

PLAYER I.D. CODE

DIST. OFFICE CODE

DATE RECEIVED

DRAW DATE

INITIALS

FOR HEADQUARTER OFFICE USE ONLY

POST MARK DATE

CODE(S)

REASON

RELEASED

CRN

CLAIMANT INFORMATION

PLEASE READ ALL INFORMATION AND INSTRUCTIONS BEFORE COMPLETING CLAIM FORM

Last Name

Date of Birth

Month Day

Year

First Name

Suffix

SSN/TIN

Address 1

Address 2

City

State

Zip Code

Country

Phone

Area Code

For tax purposes only:

TICKET INFORMATION

Attach the original ticket to this form with your legal name, signature and address showing. Enter the

information below (Scratchers 13-19 digit ticket number is located on back of ticket; Draw Game 19 digit ticket

number is located on front of ticket). Attach a separate claim form for each ticket submission.

Ticket Number:

Prize Claim: $___________________________

I declare, under penalty of perjury under the laws of the State of California, including but not limited to California

Penal Code §§ 118 and 72, that I am the rightful owner of the ticket on this form, that I am 18 years of age or older,

and that all information provided is true and correct. I understand that any person who, with intent to defraud,

falsely makes, alters, forges or counterfeits a Lottery ticket is in violation of state law and could be liable for criminal

penalties.

Claimant Signature

(Only one signature, and it must match signature on ticket)

Date

I am not a U.S. Citizen, and I am not a Resident Alien

I do not have a Social Security Number

I am a Lottery Retailer

I am employed by a Lottery Retailer

I am related to a Lottery Retailer

Cash all prizes of $599 or less at

participating Lottery Retailers

CSL 1242 (R10/22)

Page 2 of 3

Tickets,

transactions, purchases, claims and prize payments are subject to federal and state law and California

Lottery

regulations, policies and procedures. Copies of regulations are available at Lottery District Offices and on our

website

at www.calottery.com. Tickets failing validation are void.

PRIZE PAYMENT INFORMATION

Failure to provide your original signed ticket with date of birth, legal name, complete address (including

apartment or space number, city, state, zip code), email and phone number may delay or prevent the

California State Lottery (Lottery) from processing your prize claim. Claims submitted to Lottery Headquarters for

processing are paid by check and mailed from the California State Controller's Office. Processing time, once claim

is received and verified, is approximately 8 weeks. If you have questions, contact the Lottery at 1-800-

LOTTERY (568-8379), Monday through Friday.

Lottery prizes are not subject to California state income tax. The Lottery is required by federal tax law to withhold

federal taxes of 24% for U.S. citizens and resident aliens. Non-US citizens will have 30% withheld from all prizes.

INSTRUCTIONS

1. Print your legal name, street address, city, state, and zip code on the back of the ticket.

2. Sign your name on the back of the original ticket.

3. Complete the Claimant Information and Ticket Information sections on the first page of thisform.

4. Sign the first page of this form with ink. (ONLY ONE SIGNATURE IS PERMITTED)

5. Staple your original ticket to the front of this form.

KEEP A COPY OF THIS FORM AND A COPY OF THE FRONT AND BACK OF THE TICKET.

Deliver the completed claim form with original ticket to any Lottery District Office. Location and

directions can be found at www.calottery.com.

OR, MAIL THIS CLAIM FORM, AT YOUR OWN RISK, WITH THE ORIGINAL TICKET STAPLED ON THE FRONT,

TO: California Lottery, 730 North 10th Street, Sacramento, CA 95811-0336

Call 1-800-LOTTERY(568-8379), or visit any Lottery District Office to request a Multiple Ownership Claim

form for group players (less than 100) sharing prizes of $1,000,000, or more.

PRIVACY NOTICE

The Information Practices Act of 1977 (Cal. Civ. Code §§1798-1798.78, the Federal Privacy Act (Public Law 93-579), 5

U.S.C. §552a, and Cal. Gov. Code §§11015.5 and 11019.9, require that this notice be provided when collecting

personal information from individuals.

The Claimant Information requested on this form will be used to validate and process your claim in accordance with

the California State Lottery Act of 1984 (Gov. Code §8880 et seq.). The Lottery requests a player's social security or

tax identification number (SSN/TIN) for tax withholding and reporting purposes, pursuant to Internal Revenue Code

§§6011, 6041, 6109, 3402, and the regulations enacted thereunder.

The Claimant Information you provide may be disclosed to various state and federal government agencies, including

but not limited to: the State Controller's Office, Franchise Tax Board, Health and Welfare Agency, and the Internal

Revenue Service. It will not be disclosed to members of the public.

You have the right to access your personal information maintained by the Lottery by contacting the California

Lottery, 700 North 10th Street, Sacramento, CA 95811-0336 - Attention: Privacy Coordinator, Information Security

Office. The Privacy Coordinator can also be reached at 916-822-8800 or priv[email protected].

Purpose and Relevancy of Information Collected: Information is collected to validate and process a claim and for

purposes of sales, marketing, research, security investigation, legal review, surveys, and strategic planning as related

to the operations of the Lottery. By submitting this claim, you consent and agree to such use, and waive any and all

legal claims, known or unknown, related to the specified uses set forth herein. The California Lottery is subject to

public disclosure laws that allow access to certain governmental records. Your full name, the name and location of

the retailer who sold you the winning ticket, the date you won, and the amount of your winnings, including your

gross and net installment payments, are matters of public record and are subject to disclosure. The Lottery will not

disclose any other personal or identifying information without your permission unless legally required to do so. No

information will be collected or accepted from known minors. You may be asked to participate in a press conference.