TITLE 11: ALCOHOL, HORSE RACING, LOTTERY, AND VIDEO GAMING
SUBTITLE C: LOTTERY CHAPTER II: DEPARTMENT OF THE LOTTERY
PART 1770
LOTTERY (GENERAL)
SECTION 1770.APPENDIX A AFFIDAVIT
Section 1770.APPENDIX A Affidavit
AFFIDAVIT
This Affidavit is submitted by
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(officer
name)
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, on behalf of
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(company name)
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("
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"), in connection with a
proposed purchase and sale of
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certain Illinois Lottery prize payments due
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(winner's
name)
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, ("Seller").
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1.
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My name is
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. I am currently employed by
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(company
name)
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as
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(title)
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, and have been employed in
such capacity at all
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times relative to this matter. I have personal knowledge
of all of the facts contained herein and am competent to testify in support
of the facts stated in this affidavit. [OR I make the following
representations based upon information and belief.]
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2.
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Prior to Seller's execution of
a written purchase and sale agreement with
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(company
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(name)
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,
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(company
name)
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, through its employees,
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contractors and/or counsel,
had contact with Seller (and/or Seller's legal counsel and/or financial
advisors) through various written, oral or telephonic communications. A
summary of those contacts follows (include names, dates, methods and nature
of contacts):
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3.
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As of the date
of this affidavit, the following lawsuits, claims and legal actions have
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been filed
against
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(company name)
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and/or its
affiliated entities by Lottery
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winners:
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(Include brief case summary as well as case name, number
and jurisdiction.)
(Address winners of any Lottery, not just Illinois.)
(Address lawsuits, claims, etc., filed during the 3-year
period immediately preceding the date of the affidavit.)
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4.
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(company
name)
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and/or its affiliated entities is in good standing in
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its state of domicile and with any other licensing or
regulatory agency as may be required in the conduct of its business.
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5.
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The history of
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(company
name)
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is as follows:
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(company
name)
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was organized in
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(month/year)
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as a
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(type
of business)
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, having its principal place of
business as
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(city/state)
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, and has operated continuously
since that
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date. (If the type of
business organization, principal place of business or other key company
information has changed since the company's inception, please include that
information as well.)
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6.
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(company
name)
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engages in the business of
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7.
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(company
name)
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's privacy and non-harassment
policies are as
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follows:
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(Attach as exhibit if
appropriate.)
(Include the company's policies
concerning the national do-not-call registry, as it relates to the non-harassment
policy.)
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(company
name)
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has followed these policies in Illinois.
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Name
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Date
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State of
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)
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County of
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)
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Signed and sworn to before me
this
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day of
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, 20
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, by
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who is personally known to me
(or who produced as identification
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).
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NOTARY
PUBLIC
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My commission expires:
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(Seal)
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(Source: Added at 29 Ill.
Reg. 13869, effective August
29, 2005)
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