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)).









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(Signature of notary officer)







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(Seal)







_______________________________





(Title or rank of officer)







(My commission expires: _________)