STATE OF )
COUNTY OF )
I, (insert name of customer) , being first duly sworn upon oath, do hereby swear and affirm as follows:
That I have been informed that what purports to be my signature appears on the following check(s) OR draft(s) as the maker or indorser:
|CHECK NUMBER |
(or draft number)
|DATE ON ITEM ||PAYEE ||AMOUNT
That I did not sign the check(s) or draft(s) listed above either as maker or indorser. |
That the signature that appears on the instrument(s) described above is not my signature, but is instead a forgery made without my knowledge and without my approval.
That I did not participate in the negotiation of the check or draft, nor did I receive the proceeds therefrom.
The information I have regarding the forgery, how it may have occurred, and who may have participated in the making of the forgery, is as follows:
Further affiant sayeth not.
Subscribed and sworn to before me, the undersigned Notary Public, this ________ day of ___________________, __________.
My commission expires: