Substitute W-9 form for claiming promotional (non-wager) prizes

Request for Taxpayer Identification Number and Certification

Reference Number:

Prize Description:

First Name:

Last Name:

Middle (optional):

Mailing Address:

City:

State:

Zip:

Phone:

Email:

Driver's License No.:

Confirm Driver's License No.:

State Driver's License Issued:

Date of Birth (MM/DD/YYYY):

A.) for Individuals:

Social Security No.:

Confirm Social Security No.:

or B.) for Lottery Retailers or Business Owners Only:

Employer Identification No.:

Under penalties of perjury, I certify that:

I am not a spouse, child, brother, sister, or parent of the Lottery Commission, the Assistant Directors, any employee of the Oregon Lottery, members of Oregon Lottery State Police Gaming enforcement, or any Oregon Lottery vendor prohibited by contract to participate.(OAR 177-051-0040), and
I am 18 years of age or older. If the prize contains alcohol, I am 21 years of age or older, and
I did not commit forgery or attempt to defraud to receive this prize, see ORS 165.013, and
I am a U.S. citizen or other U.S. person (defined in IRS form W-9), and
The number shown on this form is my correct taxpayer identificaiton number (or I am waiting for a number to be issued to me), and
I am not subject to backup with holding because:(a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

I certify that this information is correct.

Today's date:

This form will be submitted electronically to the Oregon Lottery. Do not send to the IRS.