Ill. Admin. Code tit. 11, § 1770.APPENDIX A – Affidavit

Prior to Seller's execution of a written purchase and sale agreement with

(company name)

, through its employees,

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):

AFFIDAVIT

This Affidavit is submitted by	(officer name)	, on behalf of	(company name)
("		"), in connection with a proposed purchase and sale of
certain Illinois Lottery prize payments due	(winner's name)	, ("Seller").

1.	My name is		. I am currently employed by	(company name)
	as	(title)	, and have been employed in such capacity at all
	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.]

3.	As of the date of this affidavit, the following lawsuits, claims and legal actions have
	been filed against	(company name)	and/or its affiliated entities by Lottery
	winners:
	(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.)

4.	(company name)	and/or its affiliated entities is in good standing in
	its state of domicile and with any other licensing or regulatory agency as may be required in the conduct of its business.

5.	The history of	(company name)	is as follows:
	(company name)	was organized in	(month/year)
	as a	(type of business)	, having its principal place of business as
	(city/state)	, and has operated continuously since that
	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.)

7.	(company name)	's privacy and non-harassment policies are as
	follows:
	(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.)

	(company name)	has followed these policies in Illinois.

Name

Date

State of

)

County of

)

Signed and sworn to before me this

day of

, 20

, by

who is personally known to me (or who produced as identification

NOTARY PUBLIC

My commission expires:

(Seal)

(Source: Added at 29 Ill. Reg. 13869, effective August 29, 2005)