Dpps Check Forgery Affidavit Form printable pdf download

If your checks have been lost or stolen, please provide the information listed below, complete the Affidavit of

Forgery section, sign, and notarize. Return the completed affidavit to:

Deposit Payment Protection Services, Inc

Attn: Research Department

12005 Ford Road, Suite 600

Dallas, TX 75234-7253

For additional assistance please contact SCAN Consumer Referral Services at 1-877-382-7226.

Name:

Date:

Address:

SCAN Ref#:

City:

State & Zip:

Please verify your drivers license number and the current status of your lost or stolen checking account number

Driver’s License Number Information

Status of Checking Account

State of Issue:

DL Number:

Open

Closed

Was your DL stolen:

Yes

AFFIDAVIT OF FORGERY

STATE OF:____________________)

COUNTY OF:__________________)

I. ________________________, of the city of _______________________, county of ____________________, state

of_______________________, residing at _________________________________________, being duly sworn, deposes and

says:

Affiant states that check number__________ drawn on _____________________ (bank name), account

number___________________, dated_____________, payable to the order of _____________________________,

and in the amount of $___________, was not signed/endorsed by affiant nor was it done with affiant’s knowledge

and/or consent. Affiant further states affiant’s signature appearing on said instrument is a forgery. Affiant has

not received any benefit or value for said instrument, or any part thereof, and affiant did not present said

instrument, or any part thereof, and affiant did not present said instrument for negotiation or payment.

Affiant will testify, declare, depose or certify to the truth of any or all of the foregoing before any competent tribunal,

office or person in any legal proceeding, civil or criminal, which is now pending or which may hereafter be instituted in

connection with the matter contained in the affidavit.

Affiiant also understands that making false sworn statement is subject to federal and or state statutes and may be

punishable by fines and/or imprisonment according to the laws of his or her state.

______________________________________

Signature of Affiant

SUBSCRIBED AND SWORN TO BEFORE ME THIS______________ day of _____________, 20_____.

SEAL

______________________________

Notary Public in and for state of ______________, County

of _______________.

My Commission Expires:______________.

Dpps Check Forgery Affidavit Form

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