Missouri Lottery Winner Claim Form
[ STAPLE TICKET HERE ]
PLEASE PRINT your name, address and phone number on the back of your ticket - YOU MUST SIGN YOUR TICKET. Any
winning Missouri Lottery ticket worth $600 or less can be cashed at a licensed Lottery retailer selling that game, regardless of where the
ticket was purchased and provided the cash is available.
COMPLETE ITEMS 1-17 BELOW. Please use this form to claim INSTANT (Scratchers) or DRAW GAME prizes. You are hereby
advised that items 1, 2, 3, 4, 5, 6, 7, 8, 11, and 12 are subject to being disclosed pursuant to a request under Chapter 610, Missouri
Revised Statutes.
RETAIN A PHOTOCOPY of the front and back of your winning ticket and of this completed form for your personal records.
Staple the ticket to the top right corner of this form. Mail this form and the winning ticket to: MISSOURI LOTTERY, PO BOX 7777,
JEFFERSON CITY, MO 65102-7777, OR hand deliver your ticket and completed claim form to any Missouri Lottery oce.
A
B
C
In addition to the claim form, it is your responsibility to complete IRS Form W-9 - Request for Taxpayer Identication Number and
Certification for any taxable winnings over $600.
The Missouri Lottery loves to celebrate winners. However, as of Aug. 28, 2021, that celebration will not include winners’ names
without prior written consent, in accordance with § 313.303 RSMo. As a result, the names of Lottery winners, including
promotional winners, will no longer be made available at MOLottery.com, our mobile app, etc.
Claimant’s Signature:
Date:
17. Under penalty of perjury, I declare that the name, address and Social Security number, which I have furnished, correctly
identies me as the recipient of the prize claimed, that the ticket attached to this form has not been falsely made, altered,
forged or counterfeited and all information set out above is correct.
1. Last Name
2.
First Name
3.
M.I. 4. Date of Birth
MM
5. Mailing Address [Street, Route or PO Box#] 6. City 7. State
8.
Zip Code
9.
SSN# / FIN#
10.
Phone
11.
U.S. Resident
Y or N
[area code]
12. Amount of Prize [before taxes]
16. Are you an employee of, related by blood or marriage to, or an owner/partial owner of a business that sells Missouri Lottery tickets?
Street
DD YY
$
Ocial Missouri Lottery Claim Form
.00
Yes No
13.
Number of people claiming prize
14. If more than one claimant: Is this prize to be paid equally?
Y or N
If not equally, enter
dollar amount you
are claiming
$
15.
If “Yes,” you must state the business name
and address
City
274
South Florida Fair 2021
Form W-9
(Rev. October 2018)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
▶
Go to www.irs.gov/FormW9 for instructions and the latest information.
Give Form to the
requester. Do not
send to the IRS.
Print or type.
See Specific Instructions on page 3.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
following seven boxes.
Individual/sole proprietor or
single-member LLC
C Corporation S Corporation Partnership Trust/estate
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)
▶
Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check
LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
Other (see instructions)
▶
4 Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting
code (if any)
(Applies to accounts maintained outside the U.S.)
5 Address (number, street, and apt. or suite no.) See instructions.
6 City, state, and ZIP code
Requester’s name and address (optional)
7 List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
Social security number
– –
or
Employer identification number
–
Part II Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
Sign
Here
Signature of
U.S. person
▶
Date
▶
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
• Form 1099-INT (interest earned or paid)
• Form 1099-DIV (dividends, including those from stocks or mutual
funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X
Form W-9 (Rev. 10-2018)
