Claim Forms

I,_____________________________________________, hereby authorize HELP A CHILD SMILE to mail the winner’s cheque for the Smiley’s 50/50 raffle to my address at:

_______________________________________________________________________________________________.

I have included a copy of my signed winning ticket as well as a copy of my Government-issued photo ID with my proper name and address.

I have read the Rules of Play and confirm I am eligible to participate as I am not a Board member of HELP A CHILD SMILE, nor the spouse of a Board member, nor a person under the age of 18.

Winner’s Name: (please print) ______________________________________

Signature: ____________________________  Date: ___________________

 

HELP A CHILD SMILE (Ontario)                                      

Station Main PO Box 871 Stn Main

Welland, ON   L3B 5Y5


Lottery License #RAF1204155