WINNER SHEET

TODAY’S DATE:TIME: SUBMITTED BY:

STATION: MARKET:Atlanta, GA

CONTEST NAME/GIVEAWAY:

PRIZE(S) DESCRIPTION & APPROXIMATE RETAIL VALUE:

WINNER’S NAME (PLEASE PRINT):______DOB: ______

STREET ADDRESS: ______CITY/STATE: ______
ZIP CODE: ______TELEPHONE: ______E-MAIL: ______

SOCIAL SECURITY # :______WINNER’S SIGNATURE:______

I certify that at this time I have picked up my prize. By accepting the Prize, I confirm my understanding of the Prize valued stated above. I certify that I have read this document and agree to, understand, will comply with and meet all the eligibility requirements of the Contest Rules.

I represent that I (1) have fully complied with the Official Rules for the Contest and I have meet all of the Official Contest Rules eligibility requirements, and (2) I have committed no fraud or deception in entering the Contest or in claiming the prize or prizes awarded to me. I further represent that I am a legal U.S. resident and I have the right to enter into this Agreement. I hereby release the Station, iHeartMedia + Entertainment, Inc. its parents, affiliates, employees, talent, agents and any Contest sponsors (hereinafter the “Released Parties”) from and against any and all liabilities, losses, damages, expenses, claims, settlements or judgments of any kind whatsoever which I, my heirs, executors, and administrators, may have arising directly or indirectly from my participation in the Contest or use of the Prize. I understand that I am responsible for all federal, state, and local taxes and any other costs or expenses associated with the Prize and if the Prize is valued over $600 or if I have received a total of $600 or more collectively in prizes from this Station or any iHeartMedia within the same calendar year, Form 1099 will be filed with the IRS, as required by law. I further understand and agree that any Prize value, reported to the IRS, is calculated by information provided to the Station, by the Contest sponsor or sponsors, based on the fair market value of the prize.

I understand that: a) prizes awarded by Station, iHeartMedia and Contest Sponsors have no warranty and are given in “as is” condition; b) in the event that the prize is date specific and scheduled dates and times should have cause to be cancelled and/or rescheduled the Released Parties are not liable for compensation; c) the prize awarded may not be exchanged for cash or other prizes; d) award of the prize constitutes full and complete satisfaction of any obligation by the Released Parties.

Except where prohibited, participation in the promotion and acceptance of prize constitutes winner’s consent to the company and its agents’ permission for use of winner’s name, photograph, voice, opinions and/or hometown and state , entry or likeness in any form, in whole or in part for promotional, and trade purposes in any and all media without further payment or consideration.

ONE WINNER PER HOUSEHOLD, EVERY 30 DAYS.STATION RESERVES THE RIGHT TO EXTEND THE 30 DAY TIME LIMIT TO 90 DAYS, AT THE SOLE DISCRETION OF THE STATION, IF THE PRIZE VALUE EXCEEDS $100 DOLLARS. I CERTIFY THAT NEITHER I NOR ANYONE IN MY HOUSEHOLD (INCLUDING SPOUSES, CHILDREN, PARENTS, SIGNIFICANT OTHERS AND/OR ROOMMATES) HAVE WON A CONTEST AND/OR PRIZE FROM iHEARTMEDIA + ENTERTAINMENT, INC. IN THE LAST THIRTY (30) DAYS FROM THE DATE I WAS AWARDED THE ABOVE MENTIONED PRIZE. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY TAXES AND RELEASE ALL LIABILITY OF PRIZE DYSFUNCTION OR EXPIRATION FROM iHEARTMEDIA + ENTERTAINMENT, INC. ALL PRIZES VALUED OVER $100 WILL REQUIRE THE WINNER TO FILL OUT A W-9 TAX FORM.

For Office Use Only:

W-9 Included: YES _____ NO _____ Date Check Rec’d at Station & By:

General Ledger Account Coding:

General Manager Signature:

Form 4602