CERTIFIED WINNER CLAIM FORM

PlasmaNet Inc.
P.O. BOX 4562,
NEW YORK, NY 10163

Respond by: February 2nd, 2018

201312

• Samsung 65" 3D LED Smart TV

• Dell Inspiron Laptop Computer

• Apple iPad Mini

• $50.00 SkyAuction Savings Certificate

Use the form below to claim your prize. You are a guaranteed winner of one of the prizes listed to the left.

Authorized by: B. Kelleher

• Samsung 65" 3D LED Smart TV
• Dell Inspiron Laptop Computer
• Apple iPad Mini
• $50.00 SkyAuction Savings Certificate

Use the form below to claim your prize. You are a guaranteed winner of one of the prizes listed above.

Code No. PSN20121205

Section A: Grand Prize Value Disclosure

You have been directed to this prize claim form because you are a verified and confirmed winner of one of the prizes listed above. The Grand Prize value is:

$3,500.00

Section B: Claim Information

Note: You are a guaranteed winner of one of the prizes listed above. Fill out the form below to claim your prize.

Failure to complete this form in its entirety may result in forfeiture of your prize.

a First Name

b Last Name

c Address1

d Address2

e City

f Postal Code

g State

h Country

Your prize notification and FreeLotto entry confirmations, daily results and sponsored advertising messages will be sent by e-mail only from FreeLotto:

i Email

j Confirm Email

This confirmation is contingent upon meeting the age and residency requirement. These prizes are being offered by FreeLotto.com as part of a worldwide publicity campaign. Offer is valid for a limited time.

By clicking on “CLAIM NOW” above, I acknowledge that I have read the Official Rules, Sweepstakes Rules and and agree to be bound by them.