Congratulations! You are a potential prize winner in the "EYEMED NATIONAL DOCTORS' DAY SWEEPSTAKES (Promotion). In order to confirm your eligibility, please read the following Affidavit and attached "EYEMED NATIONAL DOCTORS' DAY SWEEPSTAKES" Official Rules (the "Official Rules"). Then, please complete the following Affidavit of Eligibility and Liability Release Form (the "Affidavit and Release"). Please read these documents carefully before completing and signing. They must be completed and signed and returned via U.S. Mail to the Sponsor within seven (7) days or you will forfeit your prize and an alternate winner will be selected.
Once we receive your Affidavit and Release and verify your eligibility qualifications, you will receive your prize. We are required by law to report to the Internal Revenue Service the fair market value of your prize. You will receive a copy of this documentation and will be responsible for all applicable taxes on the prize.
Being duly sworn, I hereby represent that I have carefully read and understand the Official Rules attached hereto. I also represent that I meet all of the eligibility requirements and limitations set forth in the Rules
I hereby represent that I am a U.S. resident residing in the United States. I am submitting this affidavit with the understanding that it will be relied upon to determine my eligibility in the Promotion.
I warrant and represent that I am at least 18 years of age.
I affirm and represent that I have complied with all of the rules and regulations of the Promotion and that I have committed no fraud or deception in entering the Promotion or in claiming any prize. I represent that I have obtained my Promotion materials through authorized, legitimate channels. I further represent that I am not an employee of the Sponsor (as defined in the Official Rules) or of any other entity stated in the Official Rules whose employees are not eligible to enter the Promotion or a member of the family of any such employee.
I understand that I am entitled to receive only the announced prize and that prizes are non-transferable, and no substitutions will be made except at the sole discretion of the Sponsor or as provided in the Official Rules.
I understand and acknowledge and hereby, for myself, my heirs, executors and administrators, do waive and release any and all rights, claims and causes of action whatsoever I may have against the Sponsor for any matter, cause or things whatsoever arising out of my acceptance and utilization of the prize that I have won in the Promotion.
I also acknowledge that I am solely responsible for all federal, state and local taxes due as a winner of this Promotion. I recognize that I may wish to seek independent counsel to determine the full extent of my tax liability under state and federal laws and regulations. I acknowledge and agree that I am responsible for all other expenses that may become due because of my winning the prize.
I hereby agree that Sponsor has neither made nor is in any manner responsible or liable for any warranty, reputation, or guarantee, express or implied, in fact or in law, relative to any prize, including but not limited to its quality, merchantability, fitness for a particular purpose, or mechanical condition.
I agree to return immediately upon demand to the Sponsor any prize or the value of said prize that has been or may be awarded to me if any statement made by me in this Affidavit is false. I declare that all information that I submit in this Affidavit is true and correct. I attest that I have read, or have had read to me, and understand all of the foregoing provisions of this Affidavit, prior to its execution, and agree to be bound by them.