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