AFFIDAVIT - UNAUTHORIZED SIGNATURE OR ENDORSEMENT
State of: ____________________ County of: ____________________ I, ___________________ (depositor), being first duly sworn, 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: ______________)