6. state / zip code 7. country 8. daytime phone number 9. social

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