NATIONAL LOTTERY

Dear Winner

This is to confirm receipt of your mail regarding your winnings claim with Batch Number: NLP/44863214257, Ref Number: NLP/34147HPG/GRCC with the Lottery Firm (National Lottery). You have been awarded a payout sum of 258,000(Two Hundred and Fifty Eight Thousand Euro) being prize money for National Lottery, lotto Draw No.: 051011263141.

Be informed that instruments of payment for the sum of 258,000 to you, is already in our possession and shall be processed upon meeting the requirements stated below.

You are required to fill the "Claims Settlement Form" below with all necessary details as required on the form and send back to us.

This form is valid for only those who have been notified by NATIONAL LOTTERY INTERNATIONAL. Fill in the required fields in the space provided below. No field should be left blank, because your particulars are needed for record purposes.

NOTE : IT IS REQUIRED YOU CLICK THE REPLY BUTTON BEFORE FILLING OUT THIS FORM, AS ALL INPUTED DATA MAY BE LOST UPON OUR RECEPTION. IN THE EVENT THAT YOUR BROWSER SETTING DOES NOT SUPPORT THIS PROGRAM e.g. html program, YOU ARE TO SEND THE REQUIRED DATA IN PLAIN TEXT FORMAT.

Please fill in the appropriate information in the space below:

Top of Form

WINNER'S CLAIM FORM
WINNER'S PERSONAL DATA
First Name: *
Middle Name:
Last Name: *

Gender:

Month Of Birth:

Day:

Year:

Marital Status:

Nationality: *

Religion:

Occupation:

Address 1: *

Address 2:

City: *

State/Province.: *

Zip Code: *

Mobile phone No.: *

House Phone No.: *

Fax No.:

Email Address: * e.g. username@domainname.com

WINNING INFORMATION

Batch Number: *

Winning Number : *

Reference Number: *

This is to verify that the information filled in this FORM is a valid particulars of me. Yes: No:

NATIONAL LOTTERY INTERNATIONAL