State of:     ____________________


County 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:    ______________________


County of: _____________________








This instrument was acknowledged before me on ___________________ (date), by,




(name(s) of person(s)).




(Signature of notarial officer)






 (Title or Rank of Officer)


 (My commission expires: ______________)