GOVERNMENT OF PUNJAB
DIRECTORATE OF PUNJAB STATE LOTTERIES
S.C.O. No. 106- 108, SECTOR -17-D, CHANDIGARH
Claim form for the prize winner (s) of Punjab state __________________
Held on___________________
1.
Name of the winner (S)
___________________________________
(In Block Letters)
2.
Minor or Major
___________________________________
3.
Father’s/ Husband Name
___________________________________
4.
Permanent Address
____________________________________
(In Block Letters)
5.
Present Address
___________________________________
6.
Telephone/ Mobile Number ___________________________________
7.
Occupation
___________________________________
8.
Pan Number
___________________________________
9.
Prize winning Ticket/
Coupon Number
___________________________________
10. Date of Draw
___________________________________
11. Amount of Prize
___________________________________
12. Detail of Account to which
the prize Amt to be transferred.
a)
Nature of Account
_________________________
b)
Account No
_________________________
c)
Name of Bank
_________________________
d)
Address of Bank
________________________
e)
IFSC Code of bank
_________________________
(Please enclose a cancelled cheque )
Date
Signature of Claimant
Advance Receipt
Received a sum of Rs. _______________ Rs.___________________________ from
Director Punjab State Lotteries, Chandigarh being the prize amount against
Ticket No. __________ of Punjab State_________________________Draw held
on ___________________
Signature of the Claimant
(With Revenue Stamp)
Instructions
1.
Affix three passport size Photographs with Claim Form out of which two
should be duly attested by 1st Class Magistrate/ Notary Public/ Oath
Commissioner any Gazetted Officers.
2.
Please enclose a cancelled cheque of account where the winning amount
is to be transferred.
3
In case of Claimant is Minor than an Affidavit from the National
Guardian/ Parent should be attached with the Claim Form.
4.
In case Prize is not claimed within the prescribed period (30 days from
the date of Gazette Notification) then reasons of this on an Affidavit
should be attached with the claim Form.