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Winner Declaration Form-Single

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					                                                                                                             Winner Declaration Form-Single
Date of Claim                            Claimant Name                                                                                 Phone No.


Customer I.D. #                          Identification                                                                                Date of Birth


Game                                     Ticket Control Number                                                                         Prize Amount


REPRESENTATION, INDEMNITY AND RELEASE

In consideration of and to induce Ontario Lottery and Gaming Corporation (the “Corporation”) to deliver the Prize, as referred to above, to the undersigned
(the “Claimant”), the Claimant hereby declares, warrants and represents that:
     1.          I (the Claimant) am the only person having any beneficial interest in the Ticket referred to above, which has been presented for the Prize;
     2.          I (the Claimant) 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;
     3.          no other person(s) has any right, interest or claim in or to the Ticket;
     4.          I (the Claimant) have fully disclosed to and informed the Corporation by indicating Yes or No, with a check mark or an “X”, where shown
                 below:
           a.    whether or not I (the Claimant) am, or any time within the one year period prior to claiming the Prize, have been:
                 an employee, owner, partner, officer or director of:
                     •    OLG retailer involved in the sale and redemption of
                          OLG lottery products                                                                                          __Y __N
                     •    OLG (Ontario Lottery and Gaming Corporation)                                                                  __Y __N
                     •    Interprovincial Lottery Corporation                                                                           __Y __N
                     •    Canadian lottery jurisdiction                                                                                 __Y __N
                     •    Key lottery Suppliers                                                                                         __Y __N
                     •    AGCO (Alcohol and Gaming Commission of Ontario)                                                               __Y __N
                     •    Accountable Ministry (Ministry of Finance (effective July 8, 2009),                                           __Y __N
                          Ministry of Government Services, Ministry of Public Infrastructure
                          and Renewal (pre July 8, 2009)
                     •    Supplier of Independent Audit services                                                                         __Y __N
                     •    Supplier of Independent Advisory services                                                                      __Y __N
                     •    Supplier of Independent Security services ; and                                                                __Y __N

           b.    of any and all
                      (i)       of my (the Claimant’s) immediate family members (meaning spouse, children, parents or siblings) and
                                                                                         __Y __N
                      (ii)        other relatives residing with me (the Claimant) who are, or who at any time
                                  within the one year period prior to claiming the Prize have
                                  been, an OLG retailer, an employee of an OLG retailer involved in the sale and redemption of OLG lottery products or an
                                  employee of OLG;                                              __Y __N
     5.          the information contained at the top of this document is accurate and forms part hereof;
     6.          upon delivery of the Prize to myself (the Claimant) by the Corporation, I (the Claimant) hereby releases and discharges the Corporation and
                 Interprovincial Lottery Corporation, and their respective employees, officers, directors, and shareholders, from any further claims, actions or
                 demands by me (the Claimant) in respect of the Ticket;
     7.          I (the Claimant) will indemnify and save the Corporation and Interprovincial Lottery Corporation harmless from and against any and all
                 actions, claims, demands or costs (including costs incurred by the Corporation or Interprovincial Lottery Corporation in defending against
                 such actions, claims or demands) of any nature whatsoever brought against the Corporation or Interprovincial Lottery Corporation or arising
                 with respect to the Ticket or the delivery of the Prize;
     8.          this document shall be binding upon the heirs, executors, administrators and assigns of myself (the Claimant) and shall enure to the benefit of
                 the Corporation and Interprovincial Lottery Corporation and their respective successors, assigns, affiliates, officers, directors, employees and
                 agents.


It is the Corporation’s routine practice to publish the claimant’s name, city, prize amount, game name, game # (INSTANT) or draw date (online) and insider
status (if any) on the Corporation’s website (olg.ca) for a period of 30 days.

I (the Claimant) will not make a claim against the Corporation for broadcasting, printing, royalty or other rights and shall have no claim against the
Corporation for invasion of privacy, infringement of copyright, or otherwise by reason of the publication or broadcasting of my (the Claimant’s) name, city,
prize amount, game name, game # (INSTANT) or draw date (online) and insider status (if any).

IN WITNESS WHEREOF, I (the Claimant) have hereto set my (the Claimant’s) hand and seal at the City of _____________________, in the Province of
________________, on the ________day of _______________, 20____.

SIGNED, SEALED AND DELIVERED                            )
In the presence of:                                     )                      _____________________________________
                                                                    )          Claimant Name
                                                                    )
___________________________________                                 )
Witness                                                             )            _____________________________________
                                                                                 Signature
The 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 purposes: for investigating and validating the prize claim; sharing the information with third parties including
the Alcohol and Gaming Commission of Ontario and police services for such investigation and validation purposes; to monitor and enforce compliance with the Ontario
Lottery and Gaming Corporation’s (OLG) Retailer Contract and Prize Claim Policy and Procedures; to publish the personal information of winners as outlined above on
olg.ca; to assist OLG in managing its lottery games and in maintaining the integrity thereof; and to comply with legal requirements. Where photocopies of certain
identification (i.e driver licences) are submitted by mail or faxed to the 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 immediate 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.

For prizes less than $10,000, one piece of valid government issued ID with date of birth is required. For mail-in claims only, attach a legible
photocopy of the required ID.
For prizes of $10,000 and more, you are required to bring two pieces of valid identification, one of which must be government issued ID with
photo of claimant and date of birth.
                                                                                                                                                   Effective October 23, 2009

				
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