AFFIDAVIT OF UNAUTHORIZED ENDORSEMENT ON CHECK
STATE OF ____________________ )
COUNTY OF ____________________, SS: )
KNOW ALL MEN BY THESE PRESENTS, that on this _____ day of ______________, _______, personally
came and appeared before me ___________________________________, of _____________________
[address], in the [City/Town] of _________________, State of ________________, as affiant, known to me,
who after being first duly sworn, deposes and says:
1. That he/she is over the age of eighteen years.
2. That on ____________ (insert date), the undersigned was shown check number ____________,
dated _____________, for the amount of $____________. The check was payable to
______________ (insert payee), and was drawn on _________________ (insert account number and
name of bank).
3. The undersigned has exami