AFFIDAVIT - UNAUTHORIZED SIGNATURE OR ENDORSEMENT
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: _____________________
(name(s) of person(s)).
(Signature of notarial officer)
(Title or Rank of Officer)
(My commission expires: ______________)