6. state / zip code 7. country 8. daytime phone number 9. social
Transcripción
6. state / zip code 7. country 8. daytime phone number 9. social
WINNER IDENTIFICATION: WINNER IDENTIFICATION: STAPLE TICKET ENGRAPE EL BOLETO TO THIS ENCORNER ESTA ESQUINA SEC. INITIALS: SEC. INITIALS: AMOUNT VALIDATED AND VERIFIED: AMOUNT VALIDATED AND VERIFIED: $ $ RETAILER #: RETAILER #: CLAIM #: CLAIM #: CLAIM CENTER REP: CLAIM CENTER REP: DATE/TIME: DATE/TIME: DATE/TIME: DATE/TIME: CHECK #: CHECK #: OTHER: OTHER: INSTRUCTIONS TO INSTRUCCIONES PARA CLAIMANT EL SOLICITANTE Al boleto, su nombre, dirección y número de teléfono y firme nombre. INSTRUCTIONS TO CLAIMANT 1. Onreverso back ofdel ticket, printescriba your name, address and telephone number and sign your su name. En esta forma, complete la información requerida en lositem puntos del 1signature alsign 14 yyour firme el punto 15. La firma en esta forma para reclamar ganancias debe sermust igualbe a la firma en for el reverso 2. On this form, complete items 1 through 14, read and sign 15. The on this claim form must match the signature on the back of ticket. Entire form completed payment. 2. On back of ticket, print your name, address and telephone number and name. 1. del boleto. Esta forma debe ser llenada completamente para recibir su pago. Attach signed ticket and mail top (white) copy of this form to: New Mexico Lottery Claim Center, PO Box 93190, Albuquerque, NM 87199-3190. Or present at the 3. On this form, complete items 1 through 15 and signature onforma this claim form must match theClaim signature on the ticket.Albuquerque, Entire form must completed for payment. en el 2. Engrape el boleto firmado y envié por correo la sign. copiaThe blanca de esta a: New Mexico Lottery Center; POback Box of 93190; NMbe 87199-3190. O preséntela 3. Lottery Claim Center located Osuna NEOsuna in Albuquerque. de Cambio la Lotería localizado enRd. 4511 Road en Albuquerque. Attach signed ticketde and mail at top4511 (white) copy of this form to: NewNE Mexico Lottery, Attn: Claim Center, PO Box 93190, Albuquerque, NM 87199-3190. Or present at the 3. Centro Keep bottom (yellow) copy of4511 this formpara forRd. your records. For questions and office hours call: 505-342-7600 or 1-800-642-6689. la copia amarilla deatesta forma sus documentos. Para respuestas a sus preguntas y las horas de oficina llame al: 505-342-7600 o 1-800-642-6689. 4. Mantenga Lotterythe Claim Center located Osuna NE in Albuquerque. the bottom (yellow) copy ofNUMBER this form for your records. Forlosquestio 4. Keep (Use 12 digit number (Use on 12back números of thealticket reverso above del boleto the barlocalizados code.) arriba del código de barras.) 1. SCRATCHER NÚMERO DE BOLETO TICKET DE SCRATCHER 1. SCRATCHER TICKET NUMBER OR U Juego Game Paquete Pack Game Pack (Use 12 digit number on back of the ticket above the bar code.) Boleto Ticket DRAWING GAME TICKET NUMBER (Use 17 digit number on the front of the ticket above the bar code.) OR (Use 35 digit number (Use on los the35 front números of the ticket al frente above del the boleto barlocalizados code.) arriba del código de barras.) DRAWINGDE NÚMERO GAME BOLETO TICKET DE NUMBER JUEGO DE SORTEO Ticket 2. PRIZE AMOUNT CLAIMED CANTIDAD AMOUNT CLAIMED $2.2. PRIZE , DE PREMIO , POR COBRAR . $4. MAILING,ADDRESS, . 3. NAME 3. NOMBRE NAME Last First 5. CITY First Primer Last Apellido 7. COUNTRY COUNTRY 7. PAÍS 8. DAYTIME PHONE NUMBER DAYTIME PHONE NUMBER 8. NÚMERO DE TELÉFONO 10. OCCUPATION 10. PROFESIÓN OCCUPATION 15. SIGNATURE 9. SOCIAL SECURITY NUMBER SOCIAL SECURITY NUMBER 9. NÚMERO DE SEGURO SOCIAL 11. EMPLOYER 11. EMPLEADOR EMPLOYER 12. CITIZENSHIP/RESIDENCY (for tax purposes - check only one box) propósitos de impuesto tax purposes check only one box) 12. CIUDADANÍA/RESIDENCIA CITIZENSHIP/RESIDENCY (for(Para Marque solamente- una caja) U.S. CITIZEN CIUDADANO U.S. CITIZEN DE LOS E.E.U.U. M.I. 5. CIUDAD CITY 4. DIRECCIÓN MAILING ADDRESS 6. STATE / ZIP CODE 6. 6. ESTADO/CÓDIGO STATE / ZIP CODE POSTAL M.I. RESIDENT ALIEN EXTRANJERO RESIDENT ALIEN RESIDENTE NON-RESIDENT ALIEN EXTRANJERO NON-RESIDENT ALIEN NO RESIDENTE 13. SEX 13. SEXO SEX MALE FEMALE MALE MASCULINO FEMALE FEMENINO 14. DATE OF BIRTH 14. FECHA DATE OF DE BIRTH NACIMIENTO SIGNATURE FIRMA I15. acknowledge that certain information in this form, such as my name, city in which I live and the prize amount won, is subject to disclosure pursuant to the New Mexico Inspection of Public Reconozco cierta información esta forma, como laNew ciudad en Ilalive cual vivo la cantidad premio ganado, sujeto alpursuant Actoasdewell Inspección de Documentos Públicos de IRecords acknowledge that certain information inArticle this form, asmi mynombre, name, in which and they prize amount won, is and subject to es disclosure to the New Mexico Inspection ofeditors Public Actque (NMSA 1978, Chapteren14, 2). tal I such understand that thecity Mexico Lottery Authority and itsdel retailers advertising agencies as the news media and their Nuevo México (NMSA 1978, capítulo14, 14,Article artículo Entiendo que la Autoridad de la Lotería de Nuevo México susdisplay, minoristas y agencias de publicidad así los of medios noticias y sus Records Act 1978, Chapter 2).2). I understand that the New Lottery Authority and its yretailers andexhibition advertising as well ascomo the news media and theirthat editors may use my (NMSA name and photograph for reproduction in any medium they seeMexico fit for the purposes of advertising, or agencies editorial use. Under penalty law, I de declare the redactores pueden mi nombre for y fotografía para in la any reproducción en cualquier medio que consideren para los propósitos de publicidad, exhibición, exposición o uso editorial. Bajo pena de may use my nameutilizar and photograph reproduction medium they see fit for the purposes of advertising, display, exhibition or editorial use. Under penalty of law, I declare that the name, addressque andel taxpayer taxpayer identifying number, which have furnished, furnished, correctly identifyme me as the the recipient recipient of the the prize prize claimed and that that or obtained obtained this ticket ticket legally. II la ley, declaro nombre, la direcciónnumber, y el número deIIimpuestos, que he suministrado, identifican correctamente comoclaimed el recipiente del premio cobrado y que he comprado o he obtenido name, address and identifying which have correctly identify me as of and II have have purchased purchased or this legally. understand that itit is is unlawful to present counterfeit, witho intent to defraud, a ticket, for the purchase thereof, or to have este boleto legalmente. Entiendo que esalter, ilegalforge, hacer,pass, alterar, forjar,or presentar falsificar, con el intento a defraudar, un boleto o recibo por issued la compra del mismo, o understand that unlawful to make, make, alter, forge, pass, present orpasar, counterfeit, with intent to defraud, a lottery lottery ticket, or or receipt receipt forde thelotería, purchase thereof, issued or purported purported topublicado have been been pretendido haber sidounder publicado por la loteríaLottery bajo elAct. ActoBy designing la Lotería de Nuevo México. Firmando abajo, reconozco lasrequirements leyes y los requisitos yathat mencionados y afirmo que por lo menos Lottery under the New New Mexico Lottery Act. By signing below, acknowledge theaforementioned aforementioned lawsand and requirements andaffirm affirm thatI am I am years age or older. issued by the Lottery the Mexico below, I Iacknowledge the laws and 1818 years ofof age ortengo older. 18 años de edad. CLAIMANT'S SIGNATURE X CLAIMANT'S FIRMA DEL COBRADOR SIGNATUREXX DATE DATE FECHA Revised 6/08 White Copy - Lottery Copia White Blanca Copy - Lotería Lottery Yellow Copy - Winner Copia Yellow Amarilla Copy- Ganador - Winner 0806FRMCLM-2 Revised Revised 7/09 7/09 0907FRMCLM-3 0907FRMCLM