Prize Claim Form

PRIZE CLAIM FORM

Prize Administrator:    Promotion/Contest Name:

RECITALS

WHEREAS, the Prize Administrator conducted the referenced promotion and designated prizes to be awarded to eligible entrants;

WHEREAS, the individual completing this form (“Claimant”) asserts that they are the eligible recipient of the prize described below and seeks distribution of that prize in accordance with the rules of the promotion and applicable law.

CLAIMANT INFORMATION

Date of Birth:    Identification Provided:    ID Number (last 4):

PRIZE DETAILS & VERIFICATION

Verification Documents Submitted (check all that apply):

Copy of government-issued photo ID
Proof of address (utility bill or similar)
Copy of winning ticket/entry
Signed affidavit of eligibility

ELIGIBILITY CERTIFICATIONS

By checking each box and signing below, Claimant certifies under penalty of perjury the following:

I am at least 18 years of age (or of the minimum age required by the promotion) and a lawful resident of the jurisdictions required by the promotion.
I meet all eligibility requirements of the promotion and did not engage in any fraudulent or prohibited conduct to obtain this prize.
I am not a current employee, officer, director, or immediate family member of any entity involved in the promotion, unless expressly permitted in the official rules.

RELEASE, TAX & PAYMENT INFORMATION

Release and Indemnity: Claimant hereby releases, holds harmless, and indemnifies the Prize Administrator, its affiliates, officers, employees, agents and representatives from any and all claims, liabilities, losses or damages arising from acceptance, possession, use or misuse of the prize, including claims for personal injury or property damage, except to the extent caused by the Administrator's gross negligence or willful misconduct.

Tax Reporting and Withholding: Claimant acknowledges that prizes may be taxable. Claimant must provide valid taxpayer identification information when requested. By submitting this form Claimant authorizes the Administrator to withhold taxes as required by law and to report prize value to tax authorities where applicable.

Mail check to mailing address on file
Direct deposit (provide bank details below)

PUBLICITY & PRIVACY

Publicity Release: Claimant hereby grants the Administrator the right to use Claimant's name, city/state, likeness and prize information for promotional and marketing purposes without further compensation, unless Claimant opts out below.

I do NOT consent to publicity; do not use my name or likeness for promotional purposes.

ACKNOWLEDGMENT & SIGNATURE

By signing below, Claimant certifies that all information provided on this form is true and correct to the best of Claimant's knowledge, that Claimant is the rightful recipient of the prize, and that Claimant has read and agrees to the terms, releases and certifications contained in this form.

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