Security Front

Proper Identification Affidavit

To complete the registration of your MichiganLottery.com account please provide your valid (non-expired) government issued photo identification* and proof of your full social security number* for review. If your address on the front of your valid government issued photo identification is not current please also attach an acceptable type of proof of residence*. Please place your valid government issued photo identification and proof of your full social security number in the appropriate boxes below then make a color copy of this form prior to signing. If the ID does not fit in the boxes provided please attach a separate sheet. Please print and sign your name on the attached sheet also. Place your valid government issued photo ID here (front). Must be colored copy.

Place your proof of full social security number here. Must be colored copy.

By signing below, I certify the following:

· I am the owner of the above or attached ID and the photo on the above or attached ID is me.

· I am at least 18 years of age or older.

· I have not fraudulently obtained, altered, or modified the above or attached identification cards. Based on the above statements, I request that Michigan Lottery review my MichiganLottery.com account and update any information that may be inaccurate. I understand that if any of the statements in this affidavit are false or misleading, the Michigan Lottery may demand immediate reimbursement for any funds transacted based on my statements.

I further understand that if any of the false or misleading statements were made with intent to defraud the State of Michigan, the Michigan Lottery may request prosecution to the full extent of the law.

Printed Name Signature Date

Please provide your completed form via one (1) of the following: 1) Mail a color copy of completed form including acceptable identification documents or attachment to MSL Processing, P.O. Box 15187, Lansing, MI 48901. 2) If your online Lottery account is fully registered, you may login to your player account and upload your requested documentation. Please make sure your form is legible. If we are still unable to verify your personal information, you may be required to visit one of Lottery’s Claim Centers to present your valid government issued photo ID, proof of full social security card, and proof of residence.

*Please reference BSL-A-2231 found at http://bit.ly/2aqRHdW for a list of acceptable forms of identification documents. Authority: Act 239 of 1972, as amended BSL-A-2256(8/16)