Form R-8350mj - Affidavit Of Refund Check Endorsement Forgery For Married Filing Jointly Filing Status

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R-8350MJ (1/16)

Affidavit of Refund check endorsement

Forgery for Married Filing Jointly

Filing Status

Notice: The person alleging forgery must sign their name 5 times in longhand and the affidavit must be executed in the presence of

the Notary Public.

State of

Parish/County of

1. We are first duly sworn and state that our names are:

Taxpayer’s First Name

Middle Init.

Last Name

Taxpayer’s SSN

Spouse’s First Name

Middle Init.

Last Name

Spouse’s SSN

Mailing Address

Email Address

City

State

ZIP

Primary Telephone Number

Secondary Telephone Number

2. We state that the endorsement signatures on the Louisiana Department of Revenue refund check listed below were not written or

authorized by us and are forgeries as evidenced by the signing of our signatures below.

Bank that check was drawn on

Check Number

Check Date

Check Amount

Sign your name five times:

Spouse signs name five times:

3. We state that we did not receive any part of the proceeds of this check, directly or indirectly, and that this affidavit is made voluntarily

for the purpose of establishing the fact that our signatures on the check are a forgery.

4. Do you know who forged your signatures?

No.

Yes. If yes, provide details and copies of anything that supports your accusation.

5. We understand this forgery is subject to investigation by local, state and federal law enforcement agencies and that we may be

required to comply with a court order or subpoena to give testimony.

6. We understand making a false sworn statement may be punishable by fines and/or imprisonment pursuant to federal and state laws.

Thus Sworn to and Subscribed Before Me, Notary, in the presence of the undersigned two witnesses, who personally came and

appeared, on this ________ day of ________________, 20____.

Taxpayer’s Signature

Spouse’s Signature

Signature of witness

Notary

Enter witness name

Enter name of Notary and Notary Number

(Must include seal)

Signature of witness

Enter witness name

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Parent category: Financial

Form R-8350mj - Affidavit Of Refund Check Endorsement Forgery For Married Filing Jointly Filing Status

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