Lottery Application
(print this application and submit to the address listed below)

Winner's Information 

Winner's Name ___________________________________________

Street Address _____________________________________________

City __________________  State ________ Zip _______

County/Parish ______________________________________________

Home Telephone ____________________________________________

Driver's License No: ______________  State_____

Social Security No: _______-________-_________

Birth date: ____/____/_____   Birth State: _______

Current Marital Status: 

Single      Married Since________  
Divorced Widowed

Maiden Name (if different) _______________________

Have you ever been divorced or widowed since you won the reward?  

Yes  No

If yes, former spouse's name:______________________

Divorce Attorney's name:_________________________

Current Spouse:

Spouse's Name:_____________________________________

Maiden Name:_______________________________________

Driver's License No: ___________________  State:_______

Social Security No: _______/_______/______ State:_______

Birth date:______/_______/________ Birth State:________

Address (if different)____________________ 
City:___________________ State:______ Zip:______________

 

 Lottery Information

State Lottery Won:_________________

Date of Drawing:_______________

Total Prize (before taxes): $____________________

Gross Amount of Your Check: $____________________

Net Amount of Your Check: $______________________

Date of Initial Payment: ___________________

Frequency of Payments:________________________

Date of Final Payment:___________________

Date  Each Payment Received: _________________

Was the winning ticket shared with others?  

Yes  No

If yes, how many winners?_________

Are the payments being made to a trustee? 

Yes  No

If yes, who is the trustee? Name:________________________

Address:___________________________________________
__________________________________________________

Have you ever sold, assigned, borrowed or garnished from your lottery payments?  

Yes  No

(If yes, explain) ___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

Have you paid all of your federal, state, and local taxes derived from your lottery payments?  

Yes  No
How did you here about us? 

Radio TV   Internet Friend Advisor Newspaper If Newspaper, which one?___________________

Comments:______________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

Documents required for funding:

Lottery Award Letter (from state lottery commission)

Option Agreement (signed)

A copy of your most recent Lottery Check or Check Stub

If direct deposit, attach copy of bank statement showing deposit

A copy of front page of most recent tax return.

Copies of two forms of identification (one must be clear photo I.D.)

A copy of Marriage License (if applicable);

A copy of Divorce Decree(s)/ and property settlement(s) (if applicable);

A copy of the Will and Probate Papers if you are receiving payments as the result of a
probated estate;

Copies of any Assignments, Revisions, or other important payments related to your lottery
winnings;

Copies of all important papers related to your bankruptcy discharge, if applicable.

Authorization to Conduct Credit and Criminal Background Check:
I herby authorize the designated representative to conduct any and all background checks and credit history reports, searches, or checks which it deems necessary or advisable.

Authorization to Release Information:
I hereby authorize the designated representatives or any of their successors, assigns, designees, agents or administrators to disclose, make available and furnish to them any and all information pertaining to my lottery award as set forth. I specifically direct that the Lottery Commission or any of their successors, assigns, designees, agents or administrators cooperate with the purchasing company listed below regarding disclosure of information pertaining or related to my lottery award payments. Please provide copies via fax or otherwise of any and all documents requested by the company listed below regarding my lottery award payments. This also authorizes Charter Financial to contact next of kin for data resources.

Applicant's Signature ___________________________________

Date _______ / ________ / ________

 

Spouse's Signature ___________________________________

Date _______ / ________ / ________

Return to:
5615 Morningside, Suite #100 - Houston, TX 77005
Telephone: 713-218-9640 Facsimile: 713-661-3801