AFFIDAVIT OF ELIGIBILITY AND LIABILITY/PUBLICITY RELEASE
AFFIDAVIT OF ELIGIBILITY AND LIABILITY/PUBLICITY RELEASE
STATE OF ____________ )
COUNTY OF _____________ )
I, ___________________, being duly sworn, say that I am, and was at the time of entry, ___ years of age, and my Social Security Number is ______________. I reside at _______________________________. My daytime telephone number is ________________ and my e-mail address is _____________________________
I am submitting this Affidavit of Eligibility and Liability/Publicity Release (“Affidavit/Release”) to Carousel Motor Group (“Sponsor”), with the understanding that it will be relied upon by Sponsor in connection with my having been awarded, subject to eligibility, the prize in the Coon Rapids Chrysler Drawing (the “Drawing”), and the ________________ prize described in the Drawing’s Official Rules and Regulations (“Official Rules”) (attached hereto).
1. I hereby represent that I have read, have complied with, and will continue to comply with all the rules, regulations, terms and conditions set forth in the Official Rules; that all of the information I have provided and will provide to Sponsor has been and will be true, accurate, and complete; that I have not perpetuated and will not perpetuate any fraud or deception in connection with the drawing; and that I have not sought to influence the outcome of the drawing other than by participating in the drawing as expressly permitted in the Official Rules. I further represent that I am neither an employee or agent of Sponsor nor the immediate family member (spouse, mother, father, sister, brother, daughter or son) or member of the same household (whether related or not) of any such employee or agent, and that I have not participated in the drawing on behalf of any such employee or agent.
2. I was ____ years of age at the time of my entry into the drawing and a resident of the State of ________________, United States of America.
3. I understand that Sponsor or its agents may be requested to advise the United States Internal Revenue Service of the value of the prize awarded to me in the form of a Form 1099, and, in connection therewith, I have attached to this Affidavit a completed Form W-9 concerning the prize.
4. I, ON BEHALF OF MYSELF, MY HEIRS, EXECUTORS AND ADMINISTRATORS, AND ANY OTHER PERSON(S) WHO MAY TAKE BY OR THROUGH ME, HEREBY RELEASE, FOREVER DISCHARGE AND AGREE TO HOLD HARMLESS SPONSOR AND ITS SUBSIDIARIES, AFFILIATES, ADVERTISING AND PROMOTIONAL AGENCIES, AND EACH OF THEIR OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, SHAREHOLDERS, AND ADVISORS (COLLECTIVELY THE “RELEASED PARTIES”), FROM AND AGAINST ANY LIABILITY FOR ANY AND ALL CLAIMS, DEMANDS, LOSSES AND LIABILITIES OF ANY NATURE WHATSOEVER WHAT I MAY NOW OR HEREAFTER BE ENTITLED TO ASSERT, INCLUDING BUT NOT LIMITED TO ANY DEATH, INJURY, LOSS OF ENJOYMENT, PROPERTY DAMAGE, OR OTHER HARM OR LOSS OF ANY NATURE, ANY CLAIMS BASED ON PUBLICITY RIGHTS, PRIVACY RIGHTS, PERSONALITY RIGHTS, “MORAL RIGHTS,” OR DEFAMATION, AND ANY AND ALL TAXES LEVIED, ASSESSED OR COLLECTED, WHETHER CAUSED BY, CONTRIBUTED TO, ARISING OUT OF, OR OTHERWISE RELATED TO THE DRAWING, THE PRIZE OR MY POSSESSION, ACCEPTANCE, USE, OR MISUSE THEREOF, OR MY OTHER ACTS OR OMISSIONS IN CONNECTION THEREWITH.
5. I have been given a fully opportunity to review and analyze this Affidavit/Release as well as the promotions in the Official Rules for this Drawing. I fully and completely understand all of the terms of this Affidavit/Release and sign it voluntarily, freely, and knowingly. I acknowledge and agree that this is a complete release and discharge of any and all claims and rights of the undersigned against the released parties, and that no action will be taken by or on behalf of the undersigned with respect to any such claims or rights, it being understood that this Affidavit/Release shall be binding upon my heirs, executors, and administrators, and anyone claiming by or through me.
6. I hereby irrevocably grant to Sponsor, and those acting with its authority, the unrestricted, absolute, perpetual, worldwide right and license to use my name, address, photograph, likeness, voice, biographical and personal background information, statements, and drawing entry, and, without limitation, any notes, photograph, film, or video or audio recording that may be taken of me or of such materials (the foregoing collectively the “Content”), without further compensation, consideration, or notice or permission to me or to any third party, and to reproduce, copy, modify, create derivative works of, display, perform, exhibit, distribute, transmit or broadcast, publicly or otherwise, or otherwise use and permit to be used the content or any part thereof, whether alone or in combination with other materials (including but not limited to text, data, images, photographs, illustrations, and graphics, video or audio segments of any nature), and any media or embodiment now known or hereafter developed (including but not limited to, any format of any computer based, internet based, electronic, magnetic, digital, laser or optical based media), in connection with Sponsor’s advertising, promotion, publicity, trade, sweepstakes or contest promotions, activities, or materials.
7. I acknowledge and agree that the Drawing, this Affidavit/Release, and the parties’ respective rights and obligations in connection herewith, will be governed and construed under the laws of the State of Minnesota, without application of its conflict of laws principles.
8. I hereby represent and warrant that all statements made by me in this Affidavit/Release are true, accurate and complete, and I hereby indemnify the released parties from and against any and all losses or damages (including attorneys’ fees) arising out of or relating to any statements or representations made by me in this Affidavit or otherwise in connection with the Drawing. I agree to return immediately upon demand to Sponsor the value of the prize that has been or may be awarded to me if any statement or representation made by me in this Affidavit/Release is discovered or believed to be false or misleading, and I acknowledge and agree that all available legal and equitable remedies may be pursued against me in connection therewith.
9. I represent and affirm that this Affidavit/Release does not conflict with any other commitments or obligations on my part. I agree that this Affidavit/Release supersedes all prior negotiations and understandings between myself and the Sponsor relating to the rights granted herein and no provision of this Affidavit/Release can be modified by any other instrument or document unless in writing and signed by me and Sponsor.
10. I have been given a full opportunity to review and analyze this Affidavit/Release as well as the Official Rules for the Drawing. I fully and completely understand all of the terms of this Affidavit/Release and sign it voluntarily, freely, and knowingly.
Subscribed and sworn to before me
this day of _____________, 2019.
Notary Public – Minnesota
My Commission Expires: