CLAIM NO.
CUNA MUTUAL GROUP
STATE & CONTRACT NO.
CUMIS Insurance Society, Inc.
P.O. Box 1221
5910 Mineral Point Road
■
Madison, WI 53701-1221
Important: The person alleging forgery
Phone: 800/637-2676
■
Fax: 608/231-7900
must complete this form in longhand.
AFFIDAVIT OF FORGERY
1. I am first duly sworn and state I am:
Name ________________________________________________________________________________________
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 time:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
State of California
County of _______________________
Subscribed and sworn to (or affirmed) before me on this ________ day of _____________________________, 20_______,
by ___________________________________________________, personally known to me or proved to me on the basis of
satisfactory evidence to be the person(s) who appeared before me.
Notary Signature_________________________________________
237-CCB-4 CA (R1/05)