Affidavit of Eligibility for Award and Release 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. 2. That they were eligible under the rules and regulations of ____________. 3. 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 ________________________ Witness