CLAIM FOR PAYMENT OF ELK, DEER, ANDOR ANTELOPE LANDOWNER

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					                                                                Effective date 8/06
   WY G&F CLAIM FOR PAYMENT OF ELK, DEER, AND/OR ANTELOPE LANDOWNER COUPONS

         PLEASE READ CAREFULLY; FAILURE TO COMPLETE FORM MAY RESULT IN NONPAYMENT.
     1. The landowner coupon claim must be signed by the deeded landowner or legal representative. The individual
         signing must either be the same individual as the name printed below or in the case of a corporation, trust,
          limited liability company, or legal partnership, an authorized agent of the entity.
     2. Coupon numbers must be listed and totaled in the appropriate columns on the back of this claim form. The
         coupon number is the six character “red” number in the upper right corner of the coupon on hand issued licenses
         or the “11” character number preceded by “LN” on computer generated licenses. Extra pages may be attached.

     3. Complete name, address and Social Security # or Federal Tax Id # in the section listed below. Only corporations,
        legal partnerships, limited liability companies and trusts should list the federal tax ID number. Please insure that
        social security # or federal tax # matches the name of the landowner listed below.

     4. On or before February 1 following the hunt year for which the license was valid, this properly completed
    coupon claim form with attached signed coupons, must be delivered or mailed to a WY Game & Fish Dept game
    warden, regional office, or Cheyenne headquarters-WY G&F Fiscal Admin 5400 Bishop Blvd, Cheyenne WY 82006
        **********ONLY CHECK ONE PAYMENT BOX LISTED BELOW*******************
IMPORTANT****** Effective July 2001, the County predator animal districts in Wyoming have the option to receive
50% of the revenue generated from landowner designated landowner coupons in that county if an agreement is in place
with the Animal Damage Management Board. Revenues so designated will be assigned to the county indicated by the
landowner’s mailing address unless the landowner assigns the revenue to another county (see county designation below).
   PAYMENT TO BE MADE TO ANIMAL DAMAGE MANAGEMENT BOARD
I, the undersigned, certify under penalty of perjury that I am the owner or legal representative of the landowner of the deeded lands in
Wyoming upon which the coupons listed on the reverse side of this document were collected from hunters who killed elk, deer, and/or
antelope on said land, that this claim is just and correct in all respects and that I designate the Animal Damage Management board, as
created by W.S. 11-6-306, to receive my payment for landowner coupons claimed on this form in accordance with W.S. 23-3-105(b).
I further acknowledge that as this designation is voluntary, the payment will still be reportable by the Wyoming State Auditor for tax
purposes, under the Social Security or Federal Tax Identification number listed below.

_________________________________________________________________________________________________________
Claimant Signature                        Date                 County Designation
                                                     OR

     PAYMENT TO BE MADE TO LANDOWNER
I, the undersigned, certify under penalty of perjury, that I am the owner or legal representative of the landowner of the deeded lands in
Wyoming upon which the coupons listed on the reverse side of this document were collected from hunters who killed elk, deer, and/or
antelope on said land, that this claim is just and correct in all respects and that payment for the listed coupons is to be made to me in
accordance with W.S. 23-3-105(b).
___________________________________________________________________________________________________________
Claimant Signature                                                           Date

IN ACCORDANCE WITH IRS CODE, SOCIAL SECURITY OR TAX ID NUMBER MUST BE PROVIDED BELOW.

                             ______________________________________________________________
                              SOCIAL SECURITY OR FEDERAL TAX IDENTIFICATION NUMBER

Print your name or the name of your Company and address:

___________________________________________________________________________________________________________
     LAST NAME                                            FIRST NAME           MIDDLE INITIAL

___________________________________________________________________________________________________________
                             STREET ADDRESS OR BOX NUMBER (mailing address)

____________________________________________________________________________________________________________
CITY                                              STATE                               ZIP CODE
                                                                                                         Effective date 8/06
FOR GAME & FISH USE ONLY:

This claim was received by me on behalf of the Wyoming Game & Fish Department on or before February 1, as required by W.S. 23-
3-105(b).

_______________________________________________________                             _________________________
Game Warden Signature                                                               Date

Warden District Code                                       Claim Number _________________

                                                Total of Coupons listed below:

Elk ______________     Deer _______________ Antelope _______________ = TOTAL coupons ________




For Landowner use only: List coupon numbers, the 11 character black number preceded by “LN”in the
upper left corner of the coupon on computer generated licenses or on hand issued licenses, the 6 character red
number in the upper right corner of the coupon, in the appropriate column and total each column. If
additional space is needed, please copy this side and complete second form also .

                ELK                               DEER                                 ANTELOPE

  1)    ________________                  ____________________                      _________________
        ________________                  ____________________                      _________________
        ________________                  ____________________                      _________________
        ________________                  ____________________                      _________________
        ________________                  ____________________                      _________________
        ________________                  ____________________                      _________________
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        ________________                  ____________________                      _________________
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        ________________                  ____________________                      _________________
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        ________________                  ____________________                      _________________
        ________________                  ____________________                      _________________
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        ________________                  ____________________                      _________________
        ________________                  ____________________                      _________________
        ________________                  ____________________                      _________________
        ________________                  ____________________                      _________________
        ________________                  ____________________                      _________________
        ________________                  ____________________                      _________________
31)     ________________                  ____________________                      _________________
        TOTAL _________                   TOTAL _____________                       TOTAL __________