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: ………………………………………………………………………