STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
FOR TREASURER’S USE ONLY
FORGED ENDORSEMENT AFFIDAVIT
Posted
__________________________
STO-CA-0034 (3/14)
C/B
__________________________
INSTRUCTIONS
RETURN COMPLETED FORMS TO:
1. Prepare in triplicate. Forward all three copies to the
address noted.
State Controller’s Office
2. PRINT or TYPE all matter entered on this form.
Disbursements Bureau - Post Issuance Unit
3. All three copies are to be signed by affiant in ink.
4. Two disinterested parties must sign all three copies in
P.O. Box 942850
ink unless Notarial Acknowledgement is made.
Sacramento, CA 94250-5871
5. If Notarial Acknowledgement is made in lieu of
witnesses, only one copy of this form need be notarized.
1.
DESCRIPTION OF WARRANT/CHECK
NAME OF PAYEE (PRINT OR TYPE)
NAME OF CO-PAYEE(S) IF ANY (PRINT OR TYPE)
ADDRESS
DATE PAID BY STATE TREASURER
SERIAL NUMBER
FUND/ACCOUNT NUMBER
AMOUNT
DATED
2.
STATEMENT OF FACTS
I, THE UNDERSIGNED, DO HEREBY SET FORTH THE FOLLOWING FACTS IN CONNECTION WITH THE ABOVE DESCRIBED
WARRANT OR CHECK:
THAT I am the owner of the above described item.
THAT the endorsement purporting to be my endorsement is a forgery and was not authorized or written for me, nor written at my direction.
THAT I have never ratified said endorsement.
THAT no part of the money paid on the item described above was received by me directly or indirectly or was applied to any use or
purpose on my behalf.
THAT I am making this statement in order that the State Treasurer may effect reimbursement through the bank(s) which guaranteed the
endorsement of the above described item.
I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
3.
AFFIANT-CO-PAYEE(S) IF APPLICABLE (ALL THREE COPIES TO BE SIGNED)
AFFIANT’S NAME -
CO-PAYEE(S) NAME(S) - FIRST, MIDDLE, LAST (PRINT OR TYPE)
FIRST, MIDDLE, LAST (PRINT OR TYPE)
AFFIANT’S SIGNATURE (SIGN IN INK - REMAIN WITHIN BORDERS)
CO-PAYEE(S) SIGNATURE(S) (SIGN IN INK - REMAIN WITHIN BORDERS)
ADDRESS (PRINT OR TYPE)
ADDRESS (PRINT OR TYPE)
DATE
TELEPHONE
DATE
TELEPHONE
(
)
(
)
THIS AFFIDAVIT MUST BE EITHER WITNESSED (BY TWO DISINTERESTED PARTIES) OR NOTARIZED.
4.
TWO WITNESSES (ALL THREE COPIES TO BE SIGNED)
SIGNATURE OF WITNESS (SIGN IN INK)
WITNESS’ NAME (PRINT OR TYPE)
ADDRESS
DATE
WITNESS’ NAME (PRINT OR TYPE)
SIGNATURE OF WITNESS (SIGN IN INK)
ADDRESS
DATE
5.
NOTARIAL ACKNOWLEDGEMENT (ONLY ONE COPY NEED BE NOTARIZED)
STAMP
SUBSCRIBED AND SWORN TO BEFORE ME THIS
________________ DAY OF _____________________________________ , YEAR _________________
NOTARY’S SIGNATURE
ADDRESS