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)

*** If Required By FederaL or State Law ***

This Section for Notary:

ACKNOWLEDGMENT

State of _________

County of ________ [COUNTY]

On [DATE] before me, [NAME OF NOTARY], notary, personally appeared [NAME OF PERSON(S) INVOLVED], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

Witness my hand and official seal.

Signature ________
Notary

My commission expires: _____

(Seal)