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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
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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. Signed:____________________________________ Subscribed and sworn to before me, the undersigned Notary Public, this ________ day of ___________________, __________. __________________________________________ Notary Public My commission expires: ___________________________________________ | |||