Affidavit Of Eligibility And Release

Return this completed and notarized document no later than five (5) days from date of the notification email.

AFFIDAVIT OF ELIGIBILITY AND RELEASE

I, Sixty Second Survey, being duly sworn, depose and say:
  1. I entered Sixty Second Survey (the “Promotion”) and understand that I am the potential winner of the Grand Prize (the “Prize”), subject to verification of my entry. I understand the Prize will not include any additional items, cash awards, or paid expenses, which will be my sole responsibility.]
  2. I understand that I am submitting this Affidavit of Eligibility and Release (“Affidavit”) to assist in determining whether I am eligible to receive the Prize in accordance with the Official Rules of the Promotion (the “Official Rules”).
  3. My date of birth is _________________________ and I am currently _____ years of age.
  4. I reside at ________________________________________________________.
  5. As of the date I entered this Promotion, through and including the date of this Affidavit, I represent that I was not and am not an employee of or a member of the immediate family of an employee of SixtySecondSurvey.com or its parent or affiliates (Collectively “Sixty Second Survey Sweepstakes”).
  6. I represent that I have fully complied with the Official Rules, the information I submitted in entering the Promotion is correct, and I have not committed any fraud or other deception in entering the Promotion or claiming my Prize.
  7. My Social Security Number is ________________________________.
  8. As stated in the Official Rules, I agree that I am responsible for paying all federal, state, and local taxes on my receipt and acceptance of the Prize.
  9. I give permission to Sixty Second Survey Sweepstakes, its parent, subsidiaries, affiliates, licensees, successors, and assigns, and those acting under their authority to use, and to authorize others to use, my name, biographical information, and likeness, throughout the world in all media now known or hereafter existing (including digital, internet, social media, websites, and mobile apps) in perpetuity for advertising, marketing, publicity, and promotion of Sixty Second Survey Sweepstakes, the Promotion, other Sixty Second Survey Sweepstakes promotions, and the products/services associated with the Promotion and for all their internal business purposes without further compensation or right of approval.
  10. If any of my statements in this Affidavit is false, I agree to return to Sixty Second Survey Sweepstakes any prize awarded to me in addition to any other remedies that Sixty Second Survey Sweepstakes may seek to enforce against me.
  11. I hold harmless, release, and discharge, on behalf of myself, and my heirs, executors, and assigns, Sixty Second Survey Sweepstakes, Administrator, and their respective officers, directors, employees, agents, parent, subsidiaries, affiliates, shareholders, successors, and assigns from any and all claims, demands, lawsuits, expenses, injuries (including death), losses, damages, and any other liability of any kind, of or to me or any other person, my property, or my rights of privacy or publicity, directly or indirectly arising out of or in connection with the Promotion (including the conduct of the Promotion, the awarding of any prizes, my participation in the Promotion, my acceptance, use, misuse, loss, or damage of or to the Prize or any other prize, and use of my name, biographical information, and likeness as permitted in Paragraph 9), even if due to the negligence, omission, or other fault of Sixty Second Survey Sweepstakes or Administrator.

By: _____________________
Printed: __________________
Date:

Sworn to before me this ___ day of _____________, 20__.

_____________________
Notary Public

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