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U.S. citizen or
U.S. Person


Please use this substitute W-9 form for claiming

(Non-Wager) Promotional Prizes

Request for Taxpayer

Identification Number and Certification

Give form to the
requestor. Do not
send to the IRS.
Please Note: All sections must be completed.
Legal Name Reference Number and Prize Description
Physical Address
Mailing Address (if different than above)
Birth Date Driver's License No. /  Confirm License No. /  State Issued
Open the calendar popup.
Email Address
Social Security Number
For individuals this is your Social Security Number (SSN).
Confirm SSN
For Lottery Retailers (or Business Owners) ONLY, this is your Taxpayer Identification Number (TIN).
Under penalties of perjury, I certify that:
1. 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
2. I am 18 years of age or older. If the prize contains alcohol, I am 21 years of age or older, and
3. I did not commit forgery or attempt to defraud to receive this prize, see ORS 165.013, and
4. I am a U.S. citizen or other U.S. person (defined in IRS form W-9), and
5. 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
6. 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 or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
7. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
Date Day Time Phone Number