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Lotto Payment Verification Form

The document is a payment verification form from Sachsen Lotto-GmbH requesting information from a lottery winner to process their prize funds, including their contact details, banking information if choosing a bank transfer, and a declaration acknowledging they have not received payment. The form asks the winner to provide their name, address, nationality, date of birth, next of kin details, reference and batch numbers, email, amount won, preferred payment option of bank transfer or courier delivery, and signature.

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fandhi
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10K views1 page

Lotto Payment Verification Form

The document is a payment verification form from Sachsen Lotto-GmbH requesting information from a lottery winner to process their prize funds, including their contact details, banking information if choosing a bank transfer, and a declaration acknowledging they have not received payment. The form asks the winner to provide their name, address, nationality, date of birth, next of kin details, reference and batch numbers, email, amount won, preferred payment option of bank transfer or courier delivery, and signature.

Uploaded by

fandhi
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Sachsen Lotto-GmbH

H
Sachsen Lotto-GmbH. Sachsen Lotto-GmbH
Central Office Information and Payment Bureau
Management and Central Services: Sachsen House,18 old broad street
Sachsen-Strasse 52, DE-13370 Postdam London, W1T 5AP

mb
Germany. Contact Person: Mr. Gray Armstrong
Phone: +44-702-305-8359
Fax: +44-870-068-8245
E-mail: [email protected]

Lotto Payment Verification Form


This Form is to be filled by the sole beneficiary of the prize Funds and return by fax or e-mail in JPEG or PDF Format
for verification and final processing before courier or optional transfer process can be initiated.

-G
*PART A
First Name (Mr/Mrs/Miss):…………………………………………………..Last Name:…………………………………………………………

Residential Address:…………………………………………………………………………………………………………. …………………………..

Nationality:…………………………………………………………………………Date of Birth:……………………………………………………..

Next of Kin’s Name and address:……………………………………………………………………………………………………………………..

Telephone №:…………………………………… ………………………………..Fax №:………………………………………………………………


tto
Occupation: ………………………………………………………………………..Marital status:………………………................................

Reference Number:………………………………………………………………Batch Number:…………………………………………………..

E-mail address:……………………………………………………………………Amount Won:…………………………………………………….

*PART B (Prize Payment Options)

Note that you are required to choose only One from the Two given options on how to claim your prize Funds and fill
Lo
in the necessary information.

1.Telegraphic/Swift Bank transfer.

Bank Name:………………………………………………………………………………………………………………………………………………….

Bank Address:……………………………………………………………………………………………………………………………………………….

Bank Account №:……………………………………………………………………………………………………………………………………………


sen

Swift/Routing/Sort Code:…………………………………………………………………………………...................................................

Beneficiary Name:………………………………………………………………………………………………………………………………………….

2.Courier/Diplomatic Service delivery

Name of Beneficiary:………………………………………………………………………………………………………………………………………

Mailing Address:…………………………………………………………………………………………………………………………………………….
*Post office or private mail bag unacceptable.
ch

*PART C
Declaration.

I…………………………………………………………hereby declare that I have not received any payment of the stated prize
Funds nor has any of my family members filed claim on my behalf. I hereby authorize Sachsen Lotto-GmbH to act as
my agent in facilitating and remittance of my prize Funds to me.

Sign/Date:………………………………..............
Sa

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