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West Virginia Lottery Prize Claim Form

Prize Claim Form
(PRIZES OF $601 AND OVER)

CLAIM INFORMATION

The West Virginia Lottery will not retain any of your information used to fill out the claim form for use in surveys, marketing, and/or solicitation purposes. The information is only used to generate the printable pdf form, and will then be erased from our server. The printed form you mail in with your winning ticket(s) and photocopied ID WILL be kept on file and retained for auditing and Federal IRS purposes.
Game               
  Last, First, Middle Initial
1. Name
2. Address

3. City

4. State Zip  -

5. Phone Number ( )  - 

6. Sex     Female   Male

7. Birth Date (mm/dd/yyyy)  /   / 

8. If not U.S. citizen, then Citizenship Number  
 

9. Prize Claimed



 

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Notice: The West Virginia Lottery strives for accuracy in reporting of winning numbers, however we cannot be responsible for complete accuracy of information due to the possible unauthorized entries and edits of our material.

EARL RAY TOMBLIN, GOVERNOR
JOHN C. MUSGRAVE, DIRECTOR, WEST VIRGINIA LOTTERY