Full Name:
U.S. Citizen?
Social Security Number:
Please enter the amount of your first receipt and click "add".
| Black | $5 |
| Blue | $20 |
| Red | $50 |
| Green | $100 |
| Purple | $500 |
| Gold | $1000 |
| Black | |
| Blue | |
| Red | |
| Green | |
| Purple | |
| Gold |
Subtotal:
Taxes:
Total Winnings:
