Form 237-Ccb-4 - Affidavit Of Forgery
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1CLAIM NO.
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STATE & CONTRACT NO.
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Important: The person alleging forgery
AFFIDAVIT OF FORGERY
must complete this form in longhand.
1.
I am first duly sworn and state I am:
Name ________________________________________________
Account Number ______________________
Mailing Address _______________________________________________________________________________
City, State, Zip ________________________________________________________________________________
Phone Number Home (_________)_________________________ Work (_________)_____________________
2.
The instrument(s) forged is/are a: (Check the appropriate box)
Check
Cash Withdrawal Voucher
Share Draft
Loan Note (including Co-maker forgery)
Other (specify) _____________________________________________________________________________
Name of Credit Union or Bank
3.
The instrument(s) is/are drawn on _________________________________________________________________
4.
On the instrument(s) I am named as the: (Check the appropriate box)
Payee/Endorser (on back of check/share draft or bottom of withdrawal voucher)
Maker (on note or face of share draft/check)
Co-maker (on a loan)
Other (specify) _____________________________________________________________________________
5.
This signature for each instrument(s) listed below and attached to this affidavit is not written nor authorized by me and
is a forgery:
Date
Instrument Number
Dollar Amount
a)
_________________________
_________________________
_________________________
b)
_________________________
_________________________
_________________________
c)
_________________________
_________________________
_________________________
(If more space is required, use a separate sheet)
6.
I did not receive any part of the proceeds of the instrument(s) listed above. This affidavit is made voluntarily for the
purpose of establishing the fact that my signature is a forgery.
7.
Do you know who forged your signatures?
Yes
No If yes, provide details on a separate page or the back of
this page.
8.
I understand this forgery is subject to investigation by local, state and/or federal law enforcement agencies. I may be
required to comply with a court order or subpoena to give testimony.
9.
I understand making a false sworn statement is subject to federal and/or state statutes and may be punishable by fines
and/or by imprisonment.
Sign your name five times:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
State of ________________________________ County of _________________________________________________
Subscribed and sworn to before me this _________ day of _______________________________________ , _________
_________________________________________ Notary
237-CCB-4 (R8/02)
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