AFFIDAVIT - UNAUTHORIZED SIGNATURE OR ENDORSEMENT
State of: ____________________
I, ___________________ (depositor), after being
sworn on oath, affirm that I reside at _____________________________ (address),
_______________________ (city), ________________ County, _____________________
(state). On _____________ (date), I was shown check number __________, dated
_____________, for the amount of $__________. The check was payable to
______________________ (payee), and was drawn on
___________________________________ (account number and name of bank).
I have examined the _________________________
(signature or endorsement) on the check described above. Though the
_____________________________ (signature or endorsement) purports to be mine,
it is a forgery. I did not execute the instrument, nor did I authorize another
person to execute it on my behalf. I have received no benefits from the
proceeds of the check. I make this affidavit to induce ___________________
(bank) to reimburse me in the check amount of $__________.
State of: ______________________
instrument was acknowledged before me on ___________________ (date), by,
(name(s) of person(s)).
(Signature of notarial officer)
Rank of Officer)
commission expires: ______________)