NSW STATUTORY DECLARATION
Statutory Declaration- -Instant Scratch-it’s $2.00 Christmas Fun Game #3175
In order to claim any prizes on the Instant Scratch-its $2.00 Christmas Fun the whole ticket needs to be presented at the Outlet.
If half of the ticket is missing and the Christmas Fun Game 3175 ticket is not presented in its entirety, you will need to complete
this Statutory Declaration for NSW Lotteries to process any payment. This Statutory Declaration is to declare that you are the
rightful owner of this ticket and cannot be used if the whole ticket has been lost. This Statutory Declaration cannot be used
for any other Instant Scratch-its tickets
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Successful claims will be paid after the claim period (8 Weeks) has lapsed from date the claim was received.
The Statutory Declaration on this form must be completed prior to the claim proceeding.
This form must include details of where the ticket was purchased.
Please forward completed form to: ADMINISTRATION, PO Box 6687,Silverwater NSW 2128
I, __________________________________________________________________________________________________
(Full name of Declarant / Person making the Declaration)
of: ________________________________________________________________________________________________
(Address of Declarant / Person Making the Declaration)
In the State of New South Wales solemnly and sincerely declare that I am the rightful owner ticket number
____________________________________________________________________________________________________
Reason ticket cannot be presented in full: ___________________________________________________________________
____________________________________________________________________________________________________
Ticket purchased at:_______________Date Purchased__________________Time Purchased_____________________
This declaration is true and I know it is an offence to make a statutory declaration knowing it is false in a material
particular.
And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the
provisions of the Oaths Act 1900.
_____________________________
Signature of the person making this declaration
(to be signed in front of an authorised witness )
Taken and declared before me, at ______________________on this ______ day of________ 20 ___ .
(Location)
__________________________
(Signature of Authorised witness)
__________________________
(Name of witness)
(Justice of the Peace / Commissioner for Declarations / Legal Practitioner)