Form Osps.99.22 - Forged Check Affidavit Form
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FORGED CHECK AFFIDAVIT
Do not use this form unless instructed to do so by OSPS.
This legal document states that the check in question has been forged and that the employee
did not receive any funds from the payment of the check.
For legibility, complete this form online and print. You may also type the form. This form
must be notarized by a Notary Public.
I, ________________________ , residing at _____________________________
OREGON STATEWIDE
Name
Street Address
PAYROLL SERVICES
City of ____________________ , County of ____________ , State of ________________
(OSPS)
City
County
State
(503) 378-3518 fax
with a ZIP code of __________ being duly sworn, depose and say, that the endorsement of
E-mail:
ZIP Code
OSPS.Help@oregon.gov
a certain check No. _________ dated __________ , in favor of ___________________ ,
Online Resource Center:
Check Number
Check Date
Payee
for _______________________________________ , Dollars ($ __________ ), and issued
Financial/payroll
Dollar Amount of Check (in words)
Numeric Amount
by _____________________________ against the OSPS Joint Payroll Account, and
INSTRUCTIONS TO
Agency Name
EMPLOYEES:
1. Complete this form
purporting to be endorsed by me, and paid by U.S. Bank on the ___ day of __________ ,
Day
Month
online at the web
address below.
_______ , was not authorized or written by me, the affiant, and that such endorsement of
2. Print and give to your
Year
agency payroll office.
said check is a forgery.
Complete and print this
I further state that I have examined a machine copy of the original instrument and
form on the Web at:
have determined beyond any doubt that the signature endorsed thereon in my name is a
forgery and I have no knowledge of the endorsement of said check and that no part of the
money so paid by U.S. Bank was received by me, directly or indirectly, and that no part of
INSTRUCTIONS TO
PAYROLL OFFICES:
said money was applied to any use or purpose in my behalf. I understand that providing false
1. Verify all required fields
information in this affidavit may lead to prosecution and penalties as prescribed by law.
are complete.
2. Complete your agency
_______________________________
information below.
Signature of Affiant
3. Send ORIGINAL form to
OSPS. No faxed
Subscribed and sworn to before me this ____ day of __________ , ______ .
copies accepted.
Day
Month
Year
Agency Number
________________________________ , Notary Public in
Signature of Notary
Agency Contact
(please print)
and for the County of _______________ , State
OSPS Use Only
County
(SEAL)
Received Date Stamp
of _____________ .
State
My commission expires on ____________ .
Date
For OSPS Use Only
□
Order redeemed check, make two copies
Sent to Treasury _________________ (date / initials)
□
Make two copies of original affidavit
Treasury receipt confirmation _____________(date)
Revised 2/2016
Resolution: □ Denial ________(date) □ Fund Reimbursement _______ (date)
Form No. OSPS.99.22
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