PRIZE CLAIM FORM OVER £20 PAID BY CHEQUEGREENWICH & BEXLEY COMMUNITY HOSPICE BE A STAR SUPPORT OUR NURSES – SCRATCH

CARDS

Print your name, address, phone number on back of ticket and sign your name

Complete items 1 through to 10 on this form Staple ticket to bottom of form shown below

CLAIM INFORMATION

If not claiming in person,MAIL AT OWN RISK TO:-

Freepost RTJU-GSSJ-KEASGreenwich & Bexley Community

Hospice185 BOSTALL HILL

LONDONSE2 0GB

020 8320 5785

1. First Name: …………………………………………………………………………….……………..

Claimant’s Declaration:-

2. Surname: .……………………………………………………………………………………………….

I hereby claim payment for any prizes

3. Address: ……………………………………………………………………………………………..…..

……………………………………………………………………………………..……………………………………..4. Town:

………………………………………………………………………………………………………..

5. County: …………………………………………………………………………………………………..

6. Post Code: ………………………………………………………………………….………………..

7. Home/Mobile No: ……………………………………………………………………………..

associated with the attached scratchcard(s) and I declare that: To the best of my knowledge andbelief all of the information in this claimis true and correct; I am over the age of 16 years; and I am the rightful owner of theattached scratch card(s)

8. Date of Birth: Day Month Year

I understand that: It is an offence under the Rules ofAuthorised Lotteries to make a false ormisleading claim.

9. Prize Claimed: £ ……………………………………………

………………………..Claimants Signature:……………………………………………………………………………….

10. Date: …………………………………………………………………..

STAPLETICKETHERE

FOR LOTTERY USE ONLY

Received by: ……………………………………………………………………………….……….…

Processed by: ……………………………………………………………………………………..…

Date: ………………………………………………………………………………………………………..…

Shop purchased from: ………………………………………………………………………