FINANCE DEPARTMENT

POINTS TO TAKE CARE FOR CLAIM PRIZE

ALL THE ENTRIES IN THE CLAIM FORMS SHOULD BE CLEAR AND FILLED ONLY INCAPITAL LETTERS.

 EVERY WINNER/CLAIMANT SHOULD SUBMIT HIS/HER CLAIM IN THE PRESCRIBED FORM FOR
ALL THE PRIZES EXCEEDING ₹ 10,000/- WHETHER IN A SINGLE TICKET OR IN AGGREGATE TO
THE DIRECTOR, SIKKIM STATE LOTTERIES/INSPECTOR.
 PLEASE ENSURE TO MENTION YOUR NAME WITH SIGNATURE AND ADDRESS AT THE BACK OF
YOUR PRIZE-WINNING TICKET.

 PLEASE MAKE SURE TO FILL IN CORRECT ADDRESS WITH PIN CODE; CORRECT LOTTERY
NAME; DRAW NO.; DRAW DATE AND OTHER REQUISITE DETAILS OF PRIZES THAT YOU ARE
CLAIMING.

 AN AFFIDAVIT FROM A NOTORY PUBLIC/1ST CLASS MAGISTRATE/OATH COMMISSIONER IS A

MUST.

 THREE (3) RECENT ATTESTED PASSPORT SIZED PHOTOGRAPHS (ONE ON CLAIM FORM AND
TWO ON THE AFFIDAVIT) ALONG WITH A PHOTO IDENTITY PROOF ARE REQUIRED WITH EACH
CLAIM.

 ONE PHOTOCOPY OF THE FILLED IN CLAIM FORMS; AFFIDAVIT AND OTHER DOCUMENTS OF
YOUR CLAIMS SHOULD BE ATTACHED WITH YOUR ORIGINAL CLAIM PAPERS.

 SUBMISSION OF PERMANENT ACCOUNT NUMBER (PAN No.) ALONG WITH A COPY OF

THE PAN CARD IS A MUST FOR DEDUCTION OF INCOME TAX ON ANY PRIZE WINNINGS FROM
LOTTERY ABOVE ₹10,000/-

 PLEASE PASTE A REVENUE STAMP ON THE CLAIM FORM AND SIGN ON IT.

 BANK DETAILS WHICH SHOULD INCLUDE BANK NAME; BRANCH OF THE BANK;
I.F.S.C. CODE OF THE BANK; YOUR ACCOUNT NUMBER SHOULD BE WRITTEN LEGIBILY

 A CANCELLED CHEQUE LEAF OF THE BANK ACCOUNT WHERE THE RTGS/NEFT TRANSFER IS TO
BE CREDITED TO YOUR ACCOUNT.
 YOUR MOBILE NUMBER SHOULD BE INDICATED CLEARLY TO ENABLE PROMPT COORDINATION
BY THIS OFFICE IF REQUIRED.

 TAMPERED TICKETS SHALL NOT BE ENTITLED TO ANY PRIZE AND ANY PERSON CLAIMING
PRIZE MONEY WITH A TAMPERED TICKET IS LIABLE TO BE SUED IN A COURT OF LAW.
 GOVERNMENT OF SIKKIM SHALL NOT BE LIABLE TO PAY PRIZES ON TICKETS LOST IN POSTAL
TRANSIT, DEFACED OR MUTILATED.
 THE DIRECTORATE OF SIKKIM STATE LOTTERIES SHALL PUBLISH PERSONAL DETAILS SUCH AS NAME,
ADDRESS INCLUDING PHOTO OF THE WINNER OF A PRIZE AMOUNT ABOVE ₹10,000/- IN THE NEWSPAPERS,
MAGAZINE, TELEVISION, RADIO, OUTDOOR MEDIAS, SOCIAL MEDIAS & ONLINE WEBSITES. THE WINNER
WHO IS PRODUCING ORIGINAL TICKET SHALL BE REQUIRED TO FILL THE CLAIM FORM AGREEING TO THE
TERMS AND CONDITIONS AS STIPULATED THEREIN.

Principal Director
Sikkim State Lotteries
Government of Sikkim.
 C L A I M F O R M
[FOR PRIZE CLAIM FORM OF SIKKIM STATE LOTTERIES]

Please Tick Below (This form shall be submitted by the claimant personally/Postal in physical mode only)
Sikkim West Bengal Camp Maharashtra Camp Punjab Camp
The Principal Director, The Inspector The Inspector The Inspector
Sikkim State Lotteries Sikkim State Lotteries Sikkim State Lotteries Sikkim State Lotteries
Deorali 737102, Gangtok, Sikkim House La-4 Sector -3 Flat No: B-209,2nd Floor, Mansarovar, B2-1370, Room No-5, 2nd Floor,Arya
Sikkim Salt Lake City, Kolkata -700098 CHSL,.V Road, Near Chincholi Phatak, Mohalla, Arya School Road,
Malad West, Mumbai – 400064, Maharashtra Ludhiana –141008, Punjab.

Lottery Name : Please Tick Below

Draw No: Held On: / / Upto ₹ 10,000/-
Above ₹ 10,000
Prize Winning Ticket No:

I HEREWITH SUBMIT MY PRIZE WINNING TICKET FOR YOUR KIND CONSIDERATION.

Full Name of the Prize winner :

Address:

Father’s / Husband’s Name :

Name of the Organization :
Prize Rank :
Winning Prize Amount :
Amount in words: (Rupees :
PAN Number :
Contact Number :
Aadhaar No :
Bank Account Number :
IFSC Code of the Bank :
Name of the Bank & Branch :
No. of Claims made in the current FY :
I enclose herewith the original ticket after signing and indicating my address on its reverse side. I further
enclose an Affidavit, Pan Card, one ID proof, 3 passport sized photographs and a cancelled cheque leaf of
my bank account, and I am also aware that the Directorate of State Lotteries may publish my personal
details, such as name, address and my photograph in the newspapers, magazine, television, radio, outdoor
Medias, social Medias and online websites.
Place:
Date: Claimant Signature
.

(On ₹20/- and above Stamp Paper / E- Stamp. Paper)

TO WHOM IT MAY CONCERN DECLARATION

This is to certify and affirm that the Prize Winning Lottery Ticket submitted along with the Application for
Lottery Prize Claim herewith and the details of which are set forth herein below are original and genuine Prize
Winning Lottery Ticket physically purchased by me.
Prize Winning Ticket No.
Draw Date & Draw No
Lottery Name
Place of Purchase
Name of Claimant

Address of Claimant

Mobile No. of Claimant

That I hereby declare and affirm that if the above-mentioned Prize Winning Lottery Ticket submitted by me is
found to be fabricated, tampered, duplicate, altered, colour photocopy, printed anywhere apart from the assigned
security printers, purchased from any broker/middlemen/agent, obtained from the original winner by way of
coercion/theft or any other method or found to be illegal in any manner then the concerned Authority shall be at
liberty to take appropriate legal action against me by any means and can initiate Civil and Criminal proceedings
against me.
I further declare that I shall be available for personal deposition, if the Government of Sikkim enquires on the
doubt of genuineness of my Prize Claim or Place of Purchase.

Recent Revenue Stamp

Passport
Size
Photograph

Photograph of Claimant Signature of Claimant