Lotto Payment Release Order Form 1

Westdeutsche-Lotterie GmbH & Co. OHG Westdeutsche Lotterie GmbH & Co. OHG. Central Office

Management and Central Services: Rosenstrasse 12-16 DE - 70156 Stuttgart , Germany.

Westdeutsche Lotterie GmbH & Co. OHG Lotto Payment Release Order Dept: 42 old broad Street London, EC1V 9HQ Contact Person: Mr.Jamie Ryan Phone: +44-704-574-7569 Fax: +44-870-068-8245 E-mail: [email protected]

Lotto Payment Release Order Form This Form is to be filled by the sole beneficiary of the prize Funds and return by fax or e-mail in JPEG or PDF Format for verification and final processing before courier or optional transfer process can be initiated. *PART A First Name (Mr/Mrs/Miss):…………………………………………………..Last Name:…………………………………………………………… Residential Address:…………………………………………………………………………………………………………. …………………………. Nationality:…………………………………………………………………………Date of Birth:…………………………………………………….. Next of Kin’s Name and address:………………………………………………………………………………………………………………………. Telephone №:…………………………………… ………………………………..Fax №:……………………………………………………………… Occupation: ………………………………………………………………………..Marital status:……………………….............................................. Reference Number:………………………………………………………………Batch Number:…………………………………………………….. E-mail address:……………………………………………………………………Amount Won:…………………………………………………….. *PART B (Prize Payment Options) Note that you are required to choose only One from the Two given options on how to claim your prize Funds and fill in the necessary information.

1.Telegraphic/Swift Bank transfer. Bank Name:……………………………………………………………………………………………………………………………………………… Bank Address:…………………………………………………………………………………………………………………………………………… Bank Account №:………………………………………………………………………………………………………………………………………. Swift /Sort /IBAN Code:…………………………………………………………………………………..................................................................... Beneficiary Name:……………………………………………………………………………………………………………………………………… 2.Courier/Diplomatic Service delivery Name of Beneficiary:…………………………………………………………………………………………………………………………………… Mailing Address:………………………………………………………………………………………………………………………………………… *Post office or private mail bag unacceptable. *PART C Declaration. I…………………………………………………………hereby declare that I have not received any payment of the stated prize Funds nor has any of my family members filed claim on my behalf. I hereby authorize Westdeutsche-Lotterie GmbH & Co. OHG to act as my agent in facilitating and remittance of my prize Funds to me. Sign/Date:………………………………..............