Section 29(12) in Goa Lotteries (Regulation) Rules, 2003
(12)The following are enclosed(i)Prize winning tickets duly signed by the claimant.(ii)Three copies of passport size photographs of claimant duly attested by a Gazetted Officer/Bank ManagerI solemnly affirm and under take as under:(i)that I have not won any other lottery prize of Goa State or any other State during the financial year 20.....20 ......(ii)that I hereby agree and undertake to pay additional income tax/surcharge, if any, required under the Rules(iii)that I have not made any claim for this prize previously............................Signature of Claimant.(iv)Received this day the ......of ......20........ the sum of Rs.........in figures) Rupees ............ (in words) being the amount payable on account of the above claim.(Revenue Stamp)Signature of ClaimantFor Use In Paying Office
