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Scratch Ticket Prize Claim Form

Congratulations on your Pending Win, Please note, ALL Fields on this form Are Required except Street Address #2- This field is Only required if submitting a Post Office Box

First Name
Last Name
Date of Birth MM/DD/YYYY
Winning Email Address
  This must be the email address you were using when you scratched a winning ticket.
Street Address #1
Street Address #2
City
State
Zip Code
Valid Phone Number
  xxx-xxx-xxxx
Winning Ticket Number
   

View Official Contest Rules

 

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