DRAFT DOCUMENT — FOR ATTORNEY REVIEW ONLY This document is a first draft prepared for legal review and should not be published or relied upon without review and approval by qualified legal counsel familiar with sweepstakes, gaming, and Tennessee law.
Prize Claims

Winner Documentation Package

Affidavit of Eligibility, Liability Release & Publicity Release

Effective Date: [INSERT DATE] Version 1.0

WINNER INSTRUCTIONS: You must complete and return all required documents within ten (10) days of winner notification. Failure to return completed documents within this period will result in disqualification and forfeiture of your prize. A replacement winner will then be selected.

Table of Contents
  1. Part A — Affidavit of Eligibility
  2. Part B — Liability Release
  3. Part C — Publicity Release
  4. Signatures & Notarization
  5. Return Instructions
Part A — Affidavit of Eligibility

I, the undersigned, being first duly sworn, state and affirm as follows:

Winner Information
Full Legal Name (print):
Date of Birth:
Residential Address:
City, State, ZIP Code:
Email Address (registered):
PoolStake Username:
Phone Number:

I affirm under penalty of perjury that the following statements are true and correct:

  1. I am at least eighteen (18) years of age.
  2. I am a legal resident of the United States residing in an eligible jurisdiction (not Idaho, Washington, or any other excluded jurisdiction).
  3. I am not an employee, officer, director, contractor, or agent of PoolStake LLC, and I am not an immediate family member or household member of any such person.
  4. I have only one (1) PoolStake account and did not create or use any other account to participate in this Sweepstakes.
  5. I did not use any automated software, bot, script, or other automated method to enter the Sweepstakes.
  6. I have read and complied with all applicable Official Sweepstakes Rules and the PoolStake Terms of Service.
  7. All information I have provided to PoolStake in connection with my account and this prize claim is true, accurate, and complete.

I understand that any false statement in this Affidavit will result in immediate disqualification and forfeiture of the prize.

Prize Claimed
Pool Name or Drawing Period:
Prize Amount:
Part B — Liability Release

In consideration of receiving the prize described above, I hereby release, discharge, and hold harmless PoolStake LLC, its officers, directors, employees, agents, affiliates, successors, and assigns (collectively, the "Released Parties") from any and all claims, demands, losses, damages, rights, and causes of action of every kind and nature, whether known or unknown, existing or future, in connection with:

  • My participation in the PoolStake Sweepstakes.
  • The awarding, receipt, possession, acceptance, or use or misuse of the prize.
  • Any travel related to the prize (if applicable).
  • Any typographical or other error in the administration of the Sweepstakes.
  • Any technical failures in the Sweepstakes platform.

I agree that the Released Parties shall not be liable for any indirect, incidental, special, consequential, or punitive damages arising from or relating to the Sweepstakes or any prize.

I agree to resolve any disputes arising from the Sweepstakes through individual arbitration as set forth in the PoolStake Terms of Service, and I waive any right to participate in any class action, collective, or representative proceeding.

I acknowledge that I am solely responsible for all federal, state, and local taxes on the prize. I agree to provide PoolStake with any tax documentation required, including a completed IRS Form W-9 (US residents) or W-8BEN (non-US residents).

Part C — Publicity Release

Note: This section is OPTIONAL in states that prohibit mandatory publicity releases. Your refusal to sign this section will NOT affect your eligibility to receive your prize.

I hereby consent to and authorize PoolStake LLC and its agents to use my name, photograph, likeness, voice, statements, and general location (city and state only) for advertising, promotional, and publicity purposes in any and all media, worldwide, without additional compensation, notice, or approval, in connection with the PoolStake Sweepstakes and PoolStake's services.

I understand this consent may include, but is not limited to: social media posts, press releases, email newsletters, the PoolStake website and mobile applications, and paid advertising.

Publicity Release Election (check one)

☐  I CONSENT to the use of my name and likeness as described above.

☐  I DO NOT CONSENT to the use of my name and likeness.

Signatures & Notarization

By signing below, I affirm that all information provided in this document is true and correct, and I agree to all terms set forth in Parts A, B, and C above.

Winner Signature:
Date:
Notarization (required for prizes valued at $10,000 or more)
State of:
County of:

Subscribed and sworn to before me this ______ day of _________________, 20______.

Notary Public Signature:
My Commission Expires:
Return Instructions

Return completed documents to:

PoolStake LLC — Prize Claims

[INSERT ADDRESS]
Knoxville, Tennessee [ZIP]

Email: hello@poolstake.app
Subject: Prize Claim — [Your Username]

All documents must be received within ten (10) days of winner notification. Documents may be submitted by email as clearly photographed or scanned attachments, or by physical mail. For prizes valued at $10,000 or more, notarized originals must be submitted by mail.