Eligibility for Award and Release, Affidavit of

STATE OF ______________________
COUNTY OF ______________________

Name of winner: ________________________________________

Name of contest: ______________________________________
Date of winning: ________________________
Date of receipt of prize: ________________________
Enter description of prize: ______________________________________

The undersigned, ________________________________________, hereby being

sworn to tell the truth states:

1. That they are the winner of the prize described above.

2. That they were eligible under the rules and regulations of ____________.

3. That they consent to use of their name, image and likeness by STATION.

4. That their social security or taxpayer identification number is: _______________.

_________________________ ______________________
Winner: Print Name & Address Driver’s License Number

________________________
Witness
 Eligibility for Award and Release, Affidavit of
Review List

This review list is provided to inform you about this document in question and assist you
in its preparation. Contests are fraught with potential problems, conflicts of interest, and
investigation by government agencies. Use this document to keep a record of awards
of any substantial size to have a complete record should anyone or agency challenge
the fairness or equity of the contest.

1. Make multiple copies. Give one to the winner; keep the other in the Contest file.