AFFIDAVIT OF ELIGIBILITY AND RELEASE
Please complete and return this Affidavit of Eligibility and Release no later than seven (7) days from the date of notification.STATE OF )
COUNTY OF )
I, ____________________________________________________, being duly sworn, depose and say:
I am ____________ years of age. My Social Security Number is__________________________.
I reside at __________________________________________________________________________.
I am submitting this Affidavit to with the understanding that it will be relied upon to determine whether I am entitled to receive the prize for which my entry has been drawn in the Enter the Vault Winter 2017 Giveaway (the "Promotion").
I understand that the prize I won is a $10,000.00 retail value ring.
I represent that I have fully complied with all of the Official Rules of the Promotion (copy attached). Without limiting the foregoing, I have committed no fraud or deception in entering the Promotion or claiming my prize. I further represent that as of the date I entered this Promotion and date of this Affidavit, I was not and am not an employee or a member of the immediate family or household of any of the Sweepstakes Entities as defined in the attached Official Rules.
I acknowledge and agree that I am responsible for all federal, state and local taxes on my prize, and that I will receive an IRS Form 1099 for the value of my prize.
I hereby grant to Fragrant Jewels LLC and its agents and assigns, without limitation, the right to use my name and likeness for any publicity without further compensation or permission.
If any statement made by me in this Affidavit is false, then, in addition to any other remedies that may be taken against me, I agree to return to the sponsor any prize awarded to me.
I hereby release, discharge and absolve Fragrant Jewels LLC and its successors, assigns, officers, principals and employees, from any and all actions, suits, claims and demands of any kind whatsoever, which I, my heirs, executors, administrators and assigns, had, now have or hereafter may have, by reason of any matter connected in any way with the Promotion, including, but not limited to the operation of the Promotion, the awarding of prizes, any loss or damage to any prize, and any action, claim or suit for personal injury or loss or damage to property in connection with the receipt and use of the prize.
Sworn to and subscribed before me this _____ day of _______________ 2017.