2010 My Coke Rewards Sweepstakes Affidavit of Eligibility, Liability & Publicity Release

Transcription

1 2010 My Coke Rewards Sweepstakes Affidavit of Eligibility, Liability & Publicity Release Please complete, sign, notarize and return this affidavit within five (5) calendar day(s) of when you were selected as a winner. If your completed affidavit is not received within this timeframe, another winner will be selected. Mail your completed affidavit to: Prize Fulfillment Services One eprize Drive Pleasant Ridge, MI I,, (Legal Name as it appears on my Birth Certificate, Social Security Card or Driver s License) hereby state that I am submitting this affidavit with the understanding that it will be relied upon to determine my eligibility to receive the Win a Snapfish Digital Frame preloaded with 100 of your favorite photos, and an HP G60t Series Notebook for which my entry has been submitted in 2010 My Coke Rewards Sweepstakes. I hereby represent that I have complied with, and will continue to comply with, all of the rules and regulations of this sweepstakes and that I have perpetrated no fraud or deception in entering the sweepstakes or in claiming any prize that may be awarded to me. I also represent that neither I nor any member of my immediate family or anyone living in my household are employees of The Coca-Cola Company, Coca-Cola Bottlers, eprize, LLC, as well as all other organizations affiliated with any prize component (the Promotional Parties ), or any of their parent corporations, subsidiaries, affiliates, agents, etc. or any entity connected with this promotion, and that neither I nor any immediate family member or any one living in my household is connected with any of the above. I understand that neither the Promotional Parties nor their parent corporations, subsidiaries, affiliates, agents, assigns, etc. or any entity connected with this sweepstakes will be responsible for any costs (including, without limitation, any federal, state or local taxes) I may incur in connection with this sweepstakes or any prize I may be awarded. I understand that upon receipt of my prize I will receive a 1099 at the end of that calendar year whether I decide to use my prize or not. I confirm that my 1099 will reflect the approximate retail value of my prize, $ I will contact my tax advisor on how to best address this issue. I hereby grant to The Coca-Cola Company the absolute right and permission to use my name, address and/or photograph in any and all advertising and promotion materials, or to refrain from doing so, in any manner or media whatsoever, worldwide, for advertising and promotional purposes in conjunction with this and similar promotions without notice to me and without further compensation. I understand and agree that I shall have no right of approval, no claim to any compensation, and no claim arising out of the use, alteration, distortion or illusionary effect or use in any composite form of my name, address, photograph or likeness. 1

2 I understand and acknowledge and hereby waive and release any and all rights, demands, losses, liabilities, claims and causes of action whatsoever which I may now or hereafter be entitled to assert, including, but not limited to any death, injury, loss of enjoyment or other harm or loss of any nature whatsoever caused by, contributed to, or arising out of any prize awarded to me in this promotion. I understand that I will be disqualified from receiving and agree to return to The Coca-Cola Company (or its designated agent) immediately upon demand any prize or the value of such prize which has been awarded to me if any statement made by me in this affidavit is false. I state further that I have read the above publicity and liability release prior to its execution, and that I fully understand its contents. I understand and agree that this is a complete RELEASE and DISCHARGE of all claims and rights of the undersigned against the Sponsors and that no action will be taken by or on behalf of the undersigned with respect to any such rights, it being understood that this release shall be binding upon the heirs, executors, and administrators of the undersigned. I attest that: My Social Security number is - - My date of birth is / / Month Day Year My home telephone number is ( ) My home address is (Street City State Zip Code) My address is (Signature) (Date) (this bottom portion must be completed by a Notary Public) STATE OF ) ) ss: COUNTY OF ) On this, day of, 20, before me personally appeared print name: to me personally known, which, being by me duly sworn, did depose and say that he/she signed the foregoing instrument and he/she acknowledged same to be his/her free act and deed. NOTARY PUBLIC 2

3 2010 My Coke Rewards Sweepstakes Affidavit of Eligibility, Liability & Publicity Release Winner Under 18 Years of Age Please complete, sign, notarize and return this Affidavit of Eligibility, Liability & Publicity Release ( Affidavit ) within five (5) calendar day(s) of the date when you received the initial notification that you are a potential winner in the 2010 My Coke Rewards Sweepstakes (the "Promotion"). If we do not receive your fully executed Affidavit within this timeframe, you will forfeit your prize and another winner may be selected in your place. Mail this fully executed affidavit to: Prize Fulfillment Services One eprize Drive Pleasant Ridge, MI I hereby state that I am submitting this Affidavit with the understanding that it will be relied upon to determine my child s eligibility to receive a/an/the Win a Snapfish Digital Frame preloaded with 100 of your favorite photos, and an HP G60t Series Notebook for which his/her entry has been submitted in the 2010 My Coke Rewards Sweepstakes. I hereby complied with, and will continue to comply with, all of the rules and regulations of this Promotion and that I have perpetrated no fraud or deception in entering the Promotion or in claiming any prize that may be awarded to me. I also represent that neither I nor any member of my immediate family or anyone living in my household are employees of The Coca-Cola Company, Coca-Cola Bottlers, eprize, LLC, as well as all other organizations affiliated with any prize component (the Promotional Parties ), or any of their parent corporations, subsidiaries, affiliates, agents, etc. or any entity connected with this promotion, and that neither I nor any immediate family member or any one living in my household is connected with any of the above. I understand that neither the Sponsors nor their parent corporations, subsidiaries, affiliates, agents, assigns, etc. or any entity connected with this Promotion will be responsible for any costs (including, without limitation, any federal, state or local taxes) I may incur in connection with this Promotion or any prize I may be awarded. I understand that upon receipt of my prize I may receive an IRS 1099 form at the end of the calendar year in which I receive my prize whether I decide to use my prize or not. I confirm that my IRS 1099 form will reflect the approximate retail value of my prize, $ I will contact my tax advisor on how to best address this issue. I hereby grant to the Sponsors the absolute right and permission to use my name, address and/or photograph in any and all advertising and Promotion materials, or to refrain from doing so, in any manner or media whatsoever, worldwide, for advertising and promotional purposes in conjunction with this and similar Promotions without notice to me and without further compensation. I shall have no right of approval, no claim to any compensation, and no claim arising out of the use, 3

4 alteration, distortion or illusionary effect or use in any composite form of my name, address, photograph or likeness. I understand and acknowledge and hereby waive and release any and all rights, demands, losses, liabilities, claims and causes of action whatsoever which I may now or hereafter be entitled to assert, including, but not limited to any death, injury, loss of enjoyment or other harm or loss of any nature whatsoever caused by, contributed to, or arising out of any prize awarded to me in this Promotion. I understand that my child will be disqualified from receiving and agree to return to The Coca-Cola Company (or its designated agent) at my sole expense any prize which may be awarded to me if any statement made by me in this Affidavit is false and I agree to return immediately upon demand to The Coca-Cola Company (or its designated agent) at my sole expense any prize or the value of such prize which has been or may be awarded to me if any statement made by me in this Affidavit is false. I state further that I have read the above publicity and liability release prior to its execution, and that I fully understand its contents. It is understood and agreed that this is a complete RELEASE and DISCHARGE of all claims and rights of the undersigned against the Sponsors and that no action will be taken by or on behalf of the undersigned with respect to any such rights, it being understood that this release shall be binding upon the heirs, executors, and administrators of the undersigned. I attest that: My Legal Name (as it appears on my Birth Certificate, Social Security Card or Driver s License) is My Social Security number is - - My date of birth is (Month/Day/Year) / / My home telephone number is ( ) - My home address is (Street City State Zip Code) My address is My child s name is My child's address is My child s date of birth is (Month/Day/Year) Signature / / Date (this bottom portion must be completed by a Notary Public) STATE OF ) ) ss: 4

5 COUNTY OF ) On this, day of, 20, before me personally appeared print name: to me personally known, which, being by me duly sworn, did depose and say that he/she signed the foregoing instrument and he/she acknowledged same to be his/her free act and deed. NOTARY PUBLIC 5