6
0/1
1
/
2
N1
O
ING
W
A
DR
JEWEL CHARITY
Order Form - Please Select Your Tickets
CHANCE TICKETS
BU Y 5 OF A KIND GE T 1 FREE
# of
(M u s t b e s a m e t i c ke t)
$150 Ticket
$100 Ticket
Choice of 2017 SLC 250 Convertible or
GLC 300 SUV Mercedes-Benz
Enjoy the “Art of Shopping” with a
$10,000 gift certificate to Eiseman
Jewels and $5,000 in NorthPark Gold.
Value up to: $50,000
Value: $15,000
$100 Ticket
$100 Ticket
Bass Performance Hall Series box
plus 6 dinners for 8 people
Shopping Spree at Fort Worth Store
Value: $12,000
Value: $10,000
$100 Ticket
$100 Ticket
Prepaid Gift Card
His and Hers custom handmade boots:
Ostrich top and bottom, with Alligator top
border (available in classic colors)
Value: $15,000
Value: $15,000
$50 Ticket
$50 Ticket
Prepaid Gift Card
Gorski Fashion Color Chinchilla Wrap
Value: $5,995
Value: $5,000
EDWARD P.
BASS
$50 Ticket
Gift Cards
Value: $5,000
F O R T
W O R T H
$50 Ticket
City and Sea Package
2 nights at The Belmont - Charleston
2 nights at Kiawah Island
Activities Included
Value: $5,000
F O R T
W O R T H
$50 Ticket
Hisun Strike 250 Kids’ UTV
$20 Ticket
_____
$150 – Choice of 2017 SLC 250 or GLC 300 Mercedes-Benz
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
$100 – Eiseman Jewels and NorthPark package
$100 – Leddy’s His and Hers Custom Handmade Boots
$100 – $15,000 Frost Prepaid Gift Card
$100 – Bass Hall Series Box plus 6 Capital Grille dinners
$100 – $10,000 Shopping Spree to FW Neiman Marcus
$50 – Gorski Chinchilla Wrap
$50 – $5,000 Worthington Prepaid Gift Card
$50 – $5,000 in Gift Cards to Central Market
$50 – Travel Experts City and Sea Package
$50 – Hisun Strike 250 Kids’ UTV
$20 – Sports Package
$20 – Dining Package (3 Chef’s Dinners for 6)
$20 – F35 Cockpit demonstration and lunch
$20 – Ladies’ Intro to Handgun course
$20 – 2 night stay at The Broadmoor
6 Lone Star Park Seats in the Silks
t Tot
al $
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
Total $ _______
4 Dallas Cowboys Founders Club tickets
4 Dallas Stars Front Row tickets
Value: $4,699
Ticke
4 Texas Rangers Tickets in Section 32
Value: $3,300
John & Elizabeth
BOSWELL
BECCA & MARK STUPFEL
$20 Ticket
$20 Ticket
$20 Ticket
Dining Package
(3 Chef’s Dinners for 6)
F35 Cockpit demonstration followed by
lunch for 4 with a test pilot
Ladies’ Intro to Handgun course for 12
1 hour class followed by
1.5 hour range time
2 Night Stay at Resort in
Colorado Springs, Colorado
Value: $3,200
Value: $2,750
Value: $1,800
Value: $1,050
$20 Ticket
ts
et
Ticke REE Tick
F
Purchaser
Phone #
Check made payable to Jewel Charity #
Cash
Card #
Expiration Date
/
Sold by
Date
(please print)
Need not be present to win.
Thank you for
your support!
Chance Tickets
DRAWING WILL BE HELD ON 12/10/16
Restrictions may apply on some prizes.
Upon tendering the Total Sale Value $__________, this amount shall be deemed to
have been irrevocably conveyed to Jewel Charity Ball, Incorporated. Net proceeds of
this drawing will help further Jewel Charity’s mission of raising funds for
Cook Children’s Medical Center.
JEWEL CHARITY
CHANCE TICKETS
BU Y 5 OF A KIND GE T 1 FREE
Prizes must be claimed by the winner between Monday, December 12, 2016 and
Friday, December 16, 2016, at the Jewel Charity Ball office at the following address:
5020 Collinwood Avenue, Suite 400, Fort Worth, Texas 76107: otherwise the
winner shall be deemed to have not accepted his or her prize and Jewel Charity Ball,
Incorporated shall be free to dispose of the prize at its sole discretion.
Jewel Charity Ball, Incorporated will redraw up to and including six (6) additional
times, in the event a prize is not accepted, before returning the unclaimed prize to
the Prize Donor.
The fair market value of any prize claimed by a winner is subject to Federal Income
Tax and may be subject to being reported to the Internal Revenue Service. The
Internal Revenue Service requires withholding on all prizes valued in excess of
$5,000. As a result, winners of such prizes must present a cashier’s check payable
to the Jewel Charity Ball, Incorporated, at the time the prize is claimed in the amount
of 25% of the fair market value of the prize less the cost of the ticket. The withheld
Federal Income Tax will be reported to you on the annual information W2G-Certain
Gambling Winnings. For additional information, consult your tax advisor.
Prizes are not subject to exchange or redemption by the donor. Tickets are nontransferrable and non-refundable.
Prize drawing will take place on Saturday, December 10, 2016.
Mail this portion of form to:
5020 Collinwood Avenue, Suite 400
Fort Worth, Texas 76107
Need not be present to win.
For more information please call 817-732-9333, ext 3
or email [email protected]
5020 Collinwood Avenue, Suite 400 | Fort Worth, Texas 76107 | jewelcharity.org