Affidavit Of Forgery - Metro Federal Credit Union
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1FO
OR OFFICE U
USE ONLY
Teller #
Date
AF
FFIDAVI
T OF FO
ORGERY
Us
se this form t
to dispute un
nauthorized o
or improper w
withdrawals f
from your ac
ccount. To
dis
spute an elec
ctronic debit, p
please use th
he Written Sta
atement Unde
er Penalty of
Perjury.
Dir
rections
1.
Fill out the fo
ollowing form
m completely.
2.
Have the form
m notarized.
3.
Return this fo
orm to Colum
mbus Metro by
y mail or in p
erson--faxed
copies canno
ot be accepte
ed.
1.
I am duly swo
orn and state I a
am
Name
Account N
Number
Address
City
State
Zip
p Code
Home Phone
Work Phon
e
2.
The instrumen
nt(s) forged is/
are (check the
e appropriate bo
ox):
Check
Share Dra
aft
Cash Withd
drawal Voucher
r
Loan Not
te (including co
o-owner forger
ry)
Other (spec
cify)
3.
The instrumen
nt(s) is/are draw
wn on METRO
FEDERAL CR
EDIT UNION.
4.
On the instrum
ment(s), I am n
named as the (
check the appr
ropriate box):
Payee/En
ndorser (on ba
ack of check/sh
hare draft or bo
ottom of withdr
rawal voucher)
Maker (o
on note or face
of share draft/
/check)
Co-make
er (on a loan)
Other (sp
pecify)
5.
. This signature
e for each inst
rument listed b
below and atta
ched to this af
ffidavit is not w
written or autho
orized
by me and is
a forgery:
DATE
IN
NSTRUMENT N
NUMBER
DOLL
LAR AMOUNT
a.
b.
c.
6.
. I did not rece
ive any part of
f the proceeds
of the instrume
ent(s) listed ab
bove. This affid
davit is made v
voluntarily for th
he
purpose of es
stablishing the
fact that my si
ignature is a fo
orgery.
Yes
No
If yes, provide
details on the
back of this p
age.
7.
. Do you know
who forged yo
our signature?
8.
. I understand
that this forger
ry is subject to
investigation b
by local, state a
and/or federal
law enforceme
ent agencies. I
may
be required to
o comply with
a court order o
or subpoena to
o give testimon
ny.
9.
. I understand
making a false
e sworn statem
ent is subject t
to federal and/o
or state statute
es and may be
e punishable by
y
fines and/or b
by imprisonme
nt.
S
ign your name
five times:
S
ubscribed and
sworn to befo
re me this
d
day of
, 20
(Notary P
Public)
Ma
ailing Addres
s
Contact
t Us
ME
ETRO Federa
al CU
By Pho
ne 847-670-0
0456
244
40 E Rand Ro
oad
By Fax
847-670-040
1
Arli
ington HtsIL 6
60004
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Parent category: Legal