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(circle 5)(circle 5)(circle 5)(circle 5) Telephone Number E-mail Address 1. CIRCLE 5 NUMBERS and 1 MEGA BALL NUMBER or CHOOSE QUICK PICK ote: If fewer than 5 numbers are circled in any game, additional number(s) will be randomly assigned. If a Mega Ball is not chosen, one will be randomly assigned. umbers chosen in excess of what is required to process this application will be disregarded. GAME PER DRAWING GROUP - If you are representing a group, enter the group name below and list group members on back.IMPORTANT: Subscriber must provide a New York State mailing address. 2. 3. PAYMENT CHECK OR MONEY ORDER 4. SUBSCRIBER INFORMATION - Please print clearly52 DRAWS52 DRAWS104 DRAWS104 DRAWS $52$104$104$208 Check or money order (payable to NY Lottery) enclosed for $ ______________. REV. 11/4GAMES PER DRAWING52 DRAWS52 DRAWS104 DRAWS104 DRAWS $104$208$208$416 GAMES PER DRAWING52 DRAWS52 DRAWS104 DRAWS104 DRAWS $156$312$312$624 GAMES PER DRAWING52 DRAWS52 DRAWS104 DRAWS104 DRAWS $208$416$416$832 MEGA BALL (circle 1) MEGA BALL (circle 1) MEGA BALL (circle 1) MEGA BALL CIRCLE YES OR NO Are you a New York City resident? Are you a Yonkers resident? Check or money order number: ____________ MEGA MILLIONS WITH MEGAPLIER PICK YOUR PLAN CHECK ONE BOX ONLY - 2 drawings per week (Tuesday and Friday) Mega Millions Jackpot Prize PaymentJackpot winners must make arrangements to receive their prize and are required to have a media announcement. If you win the Jackpot, you will have 60 days from the date the Lottery provides you with a Jackpot Claim Form to decide if you prefer 30 Annual Payments or a Lump Sum Payout. Those values are established via Mega Millions rules and will be presented to you by the Lottery shortly after a jackpot win.Prize InformationIf you match 5 numbers plus the Mega Ball and win the jackpot, you will be notied by a Lottery representative to make arrangements to receive your prize. Prizes over $600 will be mailed to you. Smaller prizes will be automatically credited to your Subscription Center prize account.You can view your prize winnings through the Subscription Center at mynylottery.org. You will be able to use your prize credits to reduce the cost of your next subscription purchase or request a cash-out of your prize credits at any time. OptionBy selecting MEGAPLIER you can multiply your non-Jackpot winnings by 2, 3, ,4 or 5. Prior to each drawing, a MEGAPLIER mutiplier is randomly selected and non-Jackpot prizes are multiplied by that amount. MEGAPLIER doubles the cost of your subscription. TaxesThe Lottery is required to report and withhold taxes according to the regulations of the Internal Revenue Service and the ew York State Department of Tax and Finance. IMPORTANT: The individual Subscriber or Group Representative must provide a mailing address withinNew York State, list the names, addresses and social security numbers of all group members in the spaces below. A maximum of 10 memb

2 ers per group is allowedBe sure to mark
ers per group is allowedBe sure to mark Yes or No to both of the questions for each group member. 1. Is the member a New York City resident?2. Is the member a Yonkers resident? Prizes of $600 or less will be creditted to the Group Representative’s account and can be used to reduce the cost of future subcriptions or can be paid by check for distributrion to the group members. Prizes greater than $600 will be divided in equal shares and paid to each member of the group. The Lottery is not re ST ZIP Social Security Number Question 1 2 Y Group Information - COMPLETE ONLY IF GROUPote: The jackpot prize will be divided equally among multiple jackpot winners. All other prizes are a xed payout amount, except as set forth below.**In some cases, the xed prizes may be paid on a pari-mutuel basis and may be lower than these published amounts. The maximum prize liability for any Mega Millions drawing, excluding jackpot prize carry-forward, is 300% of sales or 50% of sales plus $50,000,000, whichever is less. In the event that maximum prize liability is exceeded, prize levels 2 and 3 will be adjusted to reect the pari-mutuel calculated amount. Prizes/Chances of WinningFirstSecondThirdFourthFifthSixthSeventhEightinthPrizeLevelWinning Matched Per GameSectionLowerSectionChances of WinningPer GamePrizeMEGAPLIER MULTIPLIERSOT APPLY TO THE JACKPOT JACKPOT*Overall Odds of Winning on a $1 play - 1:14.71 RevisionsThe ew York Lottery reserves the right to suspend or cancel any drawing or the game itself, change the prize structure, frequency of draws or draw dates. In the event of such a change, all subscribers will receive participation in a revised game, equivalent in value to the remainder of their subscription, or a refund, at the sole option of the Lottery.Personal Information NoticeTo process your prize claim, you authorize the ew York Lottery to collect personal information about you. You authorize the ew York Lottery to use and release certain personal information, including your name, hometown and any photograph, video or audio recording, in any medium (including but not limited to newspaper, television, radio and internet), for purposes of marketing, advertising or purposes of the ew York Lottery. If you do not provide all or any part of the personal information requested, your claim might be denied and you might not be awarded a prize. The ew York Lottery is requesting this personal information pursuant to its authority under Tax Law Section 1604 to operate and administer the ew York Lottery which includes the marketing and advertising of the ew York Lottery and the identication of the person entitled to a prize award. Your personal information will be maintained by the Lottery’s Prize Payment Unit. The Director of Prize Payment is the custodian of such records and may be contacted by mail at One Broadway Center, POB 7533, Schenectady, ew York 12301-7533 or by phone at (518) 388-3370.