E-Sports Entertainment

League Prize Form

Player Information:

Identification:
First Name Eduardo
Last Name Teixeira
Date of Birth (MM / DD / YYYY) 03/24/1988
Alias DUZ-
ESEA Profile Link https://play.esea.net/users/477346

Contact Information:
E-Mail eduardomacedot@gmail.com
Phone Number +55 21 996683748
PayPal E-Mail Address

Mailing Address:
Address 1 Estrada do Catruz, 2580
Address 2 Pedra de Guaratiba
City Rio de Janeiro
State / Province RJ
Postal Code 23026-280
Country Brazil

Team Payment Information:

General Information:
Season #29 ESEA Open Brazil
Game Counter-Strike Global Offensive
Division Open
Team Information:
Team Name HARDNEJA
ESEA Team Profile Link https://play.esea.net/teams/8726378
Final Placement 3rd

Player Payment Information:

Position Name (First Name, “Alias”, Last Name) Per Player Prize Winnings
Player #1 (Captain) sir^hardneja $560
Player #2 b4rtiN 0
Player #3 Brutt 0
Player #4 v1xenBEAST 0
Player #5 DUZ- 0
Player #6
Player #7
Player #8
*If all payments are to be made to one person or company, list them as Player #1 and your submission of
this form indicates your agreement to the payment breakdown listed above.*

ET I agree that the above information is accurate.

ET I agree that I have submitted the proper tax payment forms
*Please initial each box individually.*
For Non-US Players Only, please read and complete the following certification. Please either digitally
sign or print and scan a completed copy along with the rest of the Prize Form.

To Whom It May Concern:

I, Eduardo Macedo Teixeira, certify to Turtle Entertainment Online, Inc. under penalties of perjury the
following information:

1) As evidenced by the executed W-8BEN, I am not a U.S. citizen, green card holder or resident.

2) Season 29 prize money earned by me from Turtle Entertainment Online, Inc. was in connection with
games I played while outside of the U.S.

3) I did not receive any prize money for games played inside the U.S. while on vacation or otherwise.

___________________________________________
Signature

Eduardo Macedo Teixeira______________________

Printed Name

02/05/2019__________________________________
Date

Note: If you resided in the U.S. during a period in which you earned Season 29, please contact
prizes@esportsea.com and provide an updated W-8BEN. We will assist in any questions you might have
regarding the form completion. Note that you could be subject to tax withholding amounts in accordance
with U.S. Tax Regulations.

Failure to complete this document entirely and accurately can potentially delay receiving of prize money.

Please complete this document in its entirety and save as “PFS29_LastName_FirstName_TeamName”

such as “PFS29_Levine_Craig_Team3D” and email to prizes@esportsea.com.