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.


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


  1. 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








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.



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