AFFIDAVIT FOR THE PURPOSE TO CLAIM THE PRIZE MONEY FROM THE CONCERNED AUTHORITIES OF LOTTERY DEPARTMENT

Before the Ld. Notary public at…………………(Name of place)

A F F I D A V I T

I, ___________________, S/W/D of _________________, aged about ___ years, _________(Name of religion) by religion, Business by ___________(Name of Occupation), residing at _______________________________(Address with pin code, P.O, P.S, District and State), West Bengal, hereby state as follows:-

That I had purchased a lottery ticket of __________________(Name of Organization of Lottery) of _______ ________(State Name) State Lottery, organised by Govt of ____________( State Name), for Rs.______ Bearing No. ____________ , draw to be held on ___________(dd/mm/yyyy)

That my said ticket bearing no. _________ have won the __________(1st/2nd/3rd) PRIZE OF THE SAID LOTTERY OF ______________________( Name of Organization of Lottery) DRAW OF WHICH WAS HELD ON ___________( dd/mm/yyyy).

That being the lawfull owner and holder of said ticket no. ____________. I am entitle to receive the _________(1st/2nd/3rd) prize of Rs. _________ (Rupees in word) only won by the said ticket.

That I am swearing this Affidavit for the purpose to claim the prize money from the concerned authorities of West Bengal State Lottery Department.

.I take oath and solemnly declare/affirm that the particulars furnished by me above are correct and that I have not concealed or misrepresented any facts.

Place __________.

Date ___________

_________________

D E P O N E N T

Identified by me

Advocate, __________(Name of place).