Contest Prize Claim Form

CONTEST PRIZE CLAIM FORM

WHEREAS Sponsor Name:

RECITALS

WHEREAS the Sponsor conducted a contest or sweepstakes entitled: (the "Contest"), and

WHEREAS the Claimant asserts that Claimant Name: was awarded the Prize described below on .

WHEREAS Sponsor requires a completed Prize Claim Form, representations, and release of liability prior to awarding and delivering the Prize.

CLAIMANT INFORMATION

CONTEST & PRIZE DETAILS

Mail physical prize to the address on file

Electronic funds transfer (EFT)

In-person pickup from Sponsor

SCOPE OF AWARD

Scope of Award: The Sponsor agrees to award the Prize described above and to take the actions necessary to fulfill Prize delivery as set forth below.

PAYMENT / PRIZE TERMS

Prize Payment Amount (if cash or cash-equivalent):

Payment / Delivery Schedule:

Sponsor shall not be liable for delay in delivery caused by events beyond its control. If Sponsor fails to deliver monetary prize within the stated period, a late fee of may be assessed at Sponsor's discretion.

TERM AND TERMINATION

Claim Period Start:

Claim Period End:

Notice Period for Default or Forfeiture (days):

CONFIDENTIALITY

The Claimant and Sponsor acknowledge that certain information exchanged in connection with Prize fulfillment may be confidential. Claimant agrees not to disclose non-public Sponsor information obtained in connection with prize fulfillment and to use such information only for purposes of complying with this Claim Form and facilitating delivery of the Prize.

Claimant acknowledges that Sponsor may disclose Claimant's name, city of residence, and prize description for promotional purposes unless a statutory restriction applies.

RELEASE, REPRESENTATIONS & INDEMNITY

By signing below, Claimant certifies under penalty of perjury that Claimant is the rightful recipient of the Prize, that the information provided herein is true and correct, and that Claimant will provide any additional documentation reasonably requested to verify identity and eligibility.

Claimant releases, indemnifies and holds harmless the Sponsor, its officers, directors, employees and agents from any and all claims, liabilities, losses, damages and costs (including reasonable attorneys' fees) arising out of or relating to Claimant's acceptance, possession, use or misuse of the Prize, except to the extent caused by Sponsor's gross negligence or willful misconduct.

GOVERNING LAW; ENTIRE AGREEMENT

This Claim Form and any dispute arising out of or relating to it shall be governed by the laws of the state of without regard to conflict of laws principles.

This Claim Form constitutes the entire agreement between the parties with respect to the Prize claim and supersedes all prior or contemporaneous communications and proposals, whether oral or written, relating to the Prize claim.

ATTACHMENTS & CHECKLIST

The following items must accompany this Claim Form where applicable:

Copy of government-issued photo ID

Proof of win/award notification

Completed tax reporting form where required

CERTIFICATION

I hereby certify that I am the individual named above and that I am eligible under the rules of the Contest to receive the Prize. I acknowledge and agree that Sponsor may require additional verification and that failure to provide requested documentation may result in forfeiture of the Prize. I further acknowledge that taxes on the Prize, if any, are my responsibility unless Sponsor expressly agrees otherwise in writing.

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