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: _____________________

 

 

 

 

 

 

 

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

 

 

­­­­­­­­­­­­­­­­______________________________________________________________________

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

 

 

________________________________

(Signature of notarial officer)

 

________________________________

 (Seal)

 

_______________________________

 (Title or Rank of Officer)

 

 (My commission expires: ______________)