Ruger Program Form – Fill Out and Use This PDF

Ruger Rapid Retail Rewards Program SM

2014 Redemption Form:

In order to redeem your 4R Program points, you must send us the information listed below. Please do not send us any of the following information until you are ready to claim a Ruger® Reward Firearm or Accessory. When you have accumulated enough points to qualify for a Reward Firearm or Accessory, send us:

A completed and signed 4R Program Redemption Form. Note that all sections of the form must be completed, including your social security number, which is necessary for preparation of an IRS Form 1099, if applicable;

A photocopy of your 4R Program Sales Tracking Form with the points you plan to redeem (for the specific firearms points you are using) clearly checked and dated. It is important that you include only a COPY of this sheet as you can continue to earn points and use your unredeemed 4R Program points towards other firearms and accessories;

Copies of pages 2 and 3 of the Firearms Transaction Record (Form 4473), or a print out of your electronic ATF disposition record showing model, serial number, date sold, approval number and salesperson for each qualified sale;

If redeeming for a firearm, a current copy of the FFL to whom you want the Ruger® Reward Firearm shipped (a physical copy must be sent).

All of the above information should be sent to: Ruger 4R Program, 90 Rockwood Place, Rochester, NY 14610

E M P L O Y E R I N F O R M A T I O N ( E X A C T L Y A S I T A P P E A R S O N F F L ) :

P E R S O N A L I N F O R M A T I O N :

Name (As shown on your income tax return):

SSN# (REQUIRED for IRS Form 1099)*:

Home Address:

1 Only complete this section if different from Employer information above. Reward accessories will be shipped to your home address above.

S E L E C T Y O U R F R E E I T E M :

*Under penalties of perjury, I certify that:

1.The number shown on this form is my correct social security number (or I am waiting for a number to be issued to me), and

2.I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

3.I am a US citizen or other US person.

This form may be copied or duplicated for use.

For complete Rules and Regulations, please visit the Ruger Rapid Retail Rewards ProgramSM website at www.rugerpromo.com.