LT-PZ025 (02/14)Page 1 of 2

Lottery Prize Claim Declaration Form (Single)For Prizes of $1,000 or more

For Prize Centre purposes only

Customer reference number ID type (do not record the ID number)

Date of claim (yyyy/mm/dd)

Claimant InformationLegal Name (as shown on government issued ID):First name Middle name Last name

Home address – Street number, street name, unit/apt. number, RR# or PO Box # City Province Postal code

Date of birth (yyyy/mm/dd) Home telephone number Mobile number Email address

Ticket InformationGame name Ticket number Prize amount

Notice of Collection of InformationThe personal information provided on this form is collected under the authority of the Ontario Lottery and Gaming Corporation Act, 1999 and Regulation 198/00, s. 10 and 11. This information is intended to be used for the following principal purposes, and for any further purposes reasonably necessary to give effect to these purposes: (1) investigating and validating the prize claim; (2) sharing the information with third parties, including the Alcohol and Gaming Commission of Ontario and police services, for such investigation and validation purposes; (3) monitoring and enforcing compliance with OLG’s Lottery Prize Claim Policies and Procedures; (4) publishing the personal information as described in this Declaration Form; (5) assisting OLG in managing its lottery games and in maintaining the integrity thereof; and (6) complying with legal requirements. Where photocopies of certain identification (e.g. driver's licence) are required to submit to OLG for age and residency verification and/or for identification purposes, this information will be securely destroyed after verification takes place. By submitting this type of identification, you consent to the destruction thereafter. You may visit olg.ca or speak to a Customer Service Representative for more information on the collection of this information and our Privacy Policy by calling toll-free at 1-800-387-0098.

Section A – DeclarationIn consideration of and to induce Ontario Lottery and Gaming Corporation (OLG) to deliver the Prize, as referred to above, to me (the undersigned Claimant), I hereby declare that:

Select Yes or No.

1. I am the only person having any right, interest or claim in or to the Ticket referred to above, which has been presented for the Prize. Yes No

2. Do you belong to a group, which purchased or played this Ticket? Yes No

3. I came into possession of the Ticket in a lawful and legitimate manner and in accordance with the rules and regulations governing the purchase and issuance of the Ticket. These rules and regulations are available upon request to OLG, and are also available on the OLG website at www.olg.ca.

Yes No

4. I purchased the Ticket from a lottery retailer. Yes NoIf yes, name and/or location of lottery retailer (provide both, if known). If retailer name or location is not known, please explain.

If no, please provide the name of the person who purchased the Ticket and an explanation of how you received it.Purchaser name Phone number

Explanation

Section B – Identification of Insider and Related Parties5. Within 12 months of the date of this prize claim, I am or have been:

a) a person required to be registered under the Gaming Control Act, 1992. Persons required to be registered (“Registrant”)include (A) lottery equipment suppliers, lottery retailer managers, or lottery retailers, in accordance with Regulation 281/07(Lotteries); and (B) operators, sellers, gaming-related suppliers, non-gaming related suppliers, trade unions, category 1 gaming assistants, and category 2 gaming assistants, in accordance with Regulation 78/12 (General).

Yes No

If yes, name of Registrant:

b) a director, officer, partner, sole proprietor or employee of a Registrant (as described above), and who is involved in the sale, redemption, distribution or manufacturing of lottery products, equipment or services. Yes No

If yes, name of Registrant:

c) a person who is acting on behalf of a Registrant (as described above), and who is involved in the sale, redemption,distribution or manufacturing of lottery products, equipment or services. Yes No

If yes, name of Registrant:

LT-PZ025 (02/14)Page 2 of 2

Section B – Identification of Insider (continued)d1) a member of OLG’s Board of Directors; Yes No

a full-time, part-time or student employee of OLG; Yes No

a person directly on OLG’s payroll; Yes No

an Employee of OLG on paid or unpaid leave. Yes No

d2) a director, officer or employee of Alcohol and Gaming Commission of Ontario (AGCO) Yes No

e) an individual consultant or public sector employee retained by OLG through contracts of retainer for periods of 30 calendar days or more in the aggregate. Yes No

f) a director, officer, or employee of:Interprovincial Lottery Corporation (ILC); Yes No

a Canadian provincial government lottery agency or corporation (other than OLG). Yes No

g) a member of the Ontario Provincial Police (OPP) assigned to the OPP’s AGCO Investigation and Enforcement Bureau. Yes No

h) a director, officer, partner, sole proprietor or employee of a supplier to OLG of independent audit, advisory or security services. Yes No

If yes, name of supplier:

i) an employee of an accountable Ontario Government Ministry of OLG or AGCO:Ministry of Finance; Yes No

Ministry of the Attorney General; Yes No

j) an immediate family member meaning a married spouse, common-law spouse, child, parent or sibling of a person described in Section B 5a), b), c), d), e), f), g), h) or i) above (whether living in the same residence or not), but excluding in-laws and step-family members.

Yes No

If yes, provide details of the relationship including the name of the person(s) and their place of work.

k) a relative (meaning a person other than an immediate family member) who is connected by blood or marriage and who resides with a person described in Section B 5a), b), c), d), e), f), g), h) or i) above, and includes in-laws and step-family members.

Yes No

If yes, provide details of the relationship including the name of the person(s) and their place of work.

l) an executive (e.g. President, Vice-President) of the union that represents the employees at the retail store where the Ticket was purchased. Yes No

If yes, provide the name of the union and your title.

m) involved in the repair or maintenance of OLG lottery equipment (including terminals and ticket checkers) at the retail store where the Ticket was purchased. Yes No

Section C – AcknowledgementsThis document shall be binding upon the heirs, executors, administrators and assigns of myself and shall enure to the benefit of OLG and ILC and their respective successors, assigns, affiliates, officers, directors, employees and agents. I acknowledge

To the best of my knowledge, the information contained in this document is accurate. I acknowledge

IN WITNESS WHEREOF, I have signed this document at the town/city of ,

in the province of , on the day of , 20 .

SIGNED in the presence of:

Witness name Claimant name

Witness signature Claimant signature

))

))

For prizes of $1,000 or more, it is OLG's practice to publish the winner's name, town/city, prize amount, game name, game number (INSTANT) or draw date (online) and "Insider" status (if any) on OLG's website (olg.ca) for a period of 30 calendar days from the date of the prize payment. For purposes of the Declaration Form, an "Insider" is an individual whom OLG reasonably believes meets any of the criteria identified in Section B of this Declaration Form. For major prizes of $10,000 or more, OLG shall have the right to publish in any medium, the winner's name, town/city, prize amount, game name, game number (INSTANT) or draw date (online) and a current photograph of the winner. If the claimant has answered yes to any parts of Sections B above, or if OLG reasonably believes that the claimant meets any of the criteria of Section B above, it is OLG's practice to hold payment for 30 calendar days after a tentative decision to pay the claimant has been made and during this time, publish the claimant's name, town/city, prize amount, game name, game number (INSTANT) or draw date (online) and Insider status to allow any person(s) to dispute the prize claim. An individual who met any of the criteria identified in Section B(5) d) and e) above at the time that the individual purchased the Ticket, received the Ticket as a gift, or otherwise acquired an interest in the Ticket is considered a “related party” and is not eligible to participate in a lottery and is not entitled to claim a prize in a lottery. And also in consideration of and to induce OLG to deliver the Prize to me, I agree that I will not make a claim against OLG for broadcasting, printing, royalty or other rights and shall have no claim against OLG for infringement of privacy rights, infringement of copyright, or otherwise by reason of the publication or broadcasting of my name, town/city, prize amount, game name, game number (INSTANT), draw date (online), my photograph, or Insider status (if any).

For more information, including how to claim merchandise prizes, call the OLG Support Centre at 1-800-387-0098 or visit olg.ca.