Intel(R) Giveaway Affidavit of Eligibility and Liability

I, ___________________________________________, hereby state as follows:

 

I am submitting this Affidavit with the understanding that it will be relied upon to in order for Intel to supply me with a 1099 tax form for tax reporting purposes due to the value of the gift I received.

I certify that my acceptance of any gift awarded to me (i) will not violate any law, regulation, policy or rule of my employer or agency; and (ii) is not in exchange for an agreement to influence a recent, pending or anticipated act or decision that may result in Intel obtaining or retaining business or a business advantage.

I understand I am solely responsible for all applicable taxes on any gift that may be given to me and that use of the prize may entail additional expenses for which I am fully responsible.  I also acknowledge that Intel has not arranged for and does not carry any insurance of any kind for my benefit or that of my heirs, executors and administrators relative to my use of the gift; and that I am solely responsible for obtaining and paying for any life, travel, accident, property or other insurance relative to my use of the gift.

I do hereby release and agree to indemnify and hold harmless Intel and its officers, directors, employees, representatives, agents, advertising, promotion, production and fulfillment agencies, successors and assigns from and against any liability of any kind in connection with the Promotion, including without limitation any costs, fees, expenses or damages incurred by me in use of the gift.

I agree to return the gift to Intel if any statement made by me in this affidavit is false.

I have read and understood the Official Rules. The representations and provisions contained in this Affidavit shall be binding on my heirs, successors, assigns and representatives.

 

SIGNED:

 

_________________________________________            __________________________

Recipient’s Signature                                Date                                      Daytime Phone

_________________________________________            __________________________

Address (please print)                                                                            Evening Phone

_________________________________________

City, State, Zip Code

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