Form R-8350bf - Affidavit Of Louisiana Department Of Revenue Refund Check Endorsement Forgery For A Business

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R-8350BF (8/08)
Affidavit of Louisiana Department of Revenue
Refund Check Endorsement Forgery
for a Business
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. I am first duly sworn and state I am:
Taxpayer’s Name
LA Revenue Account Number
Mailing Address
Email Address
City
State
Zip
Contact Person Name
Telephone Number
2. I state that the endorsement on the Louisiana Department of Revenue refund check listed below was not written or authorized by me and
is a forgery as evidenced by the signing of my signature below.
Bank that check was drawn on
Check number
Check date
Check amount
If the refund check was endorsed with a fraudulent signature, then sign your name five times:
3. I state that I 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 the endorsement on the check is a forgery.
4. Do you know who forged the endorsement?
No.
Yes. If yes, provide details and copies of anything that supports your accusation.
5. I understand this forgery is subject to investigation by local, state and federal law enforcement agencies and that I may be required
to comply with a court order or subpoena to give testimony.
6. I understand making a false sworn statement may be punishable by fines and/or by 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____.
Authorized Signature
Title
Signature of witness
Print witness name
Signature of witness
Notary
Print witness name
Print name of Notary and Notary Number
(Must include seal)

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