Sweepstakes Winner Affidavit Form

Sweepstakes Winner Affidavit Form
Please complete this Sweepstakes Winner Affidavit Form to verify your eligibility and affirm the accuracy of your information. Your prize may be processed based on your submission.
Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Prize Won
Declaration
Signature
Powered by Jotform SignClear
Date Signed
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: