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Lotto Payment Release Order Form 1

This document is a lottery payment release form from Westdeutsche-Lotterie GmbH & Co. OHG. It requests information from the lottery winner such as their name, address, contact details, and bank account or mailing address in order to process and deliver the prize funds via bank transfer or courier. The winner must select one payment option, fill out the necessary details, and sign the form to declare they have not received payment before and authorize the company to facilitate remittance of the prize funds.

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4K views1 page

Lotto Payment Release Order Form 1

This document is a lottery payment release form from Westdeutsche-Lotterie GmbH & Co. OHG. It requests information from the lottery winner such as their name, address, contact details, and bank account or mailing address in order to process and deliver the prize funds via bank transfer or courier. The winner must select one payment option, fill out the necessary details, and sign the form to declare they have not received payment before and authorize the company to facilitate remittance of the prize funds.

Uploaded by

baloo020379
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Westdeutsche-Lotterie GmbH & Co.

OHG
Westdeutsche Lotterie GmbH & Co. OHG. Westdeutsche Lotterie GmbH & Co. OHG
Central Office Lotto Payment Release Order Dept:
Management and Central Services: 42 old broad Street
Rosenstrasse 12-16 DE - 70156 Stuttgart , London, EC1V 9HQ
Germany. 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:………………………………..............

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