UCC ARTICLES 3 & 4 - NEGOTIABLE INSTRUMENTS - SAMPLE AFFIDAVIT OF FORGERY OR UNAUTHORIZED SIGNATURE ON A CHECK, DRAFT OR OTHER INSTRUMENT

State Of Nebraska )

) Ss.

County Of Cornhusker )

I, (insert affiant’s name, i.e., name of customer) , being first duly sworn, do hereby depose and state that:

I have been informed that what purports to be my signature appears on the following check(s), draft(s) or other instrument(s)as the maker or indorser:

Check, Draft, Instrument Number Date On Item Name Of Payee Amount

I did not sign the check(s), draft(s) or other instrument(s) listed above either as maker or indorser;

The signature that appears on check(s), draft(s) or other instrument(s) described above is not my signature, but is instead an unauthorized signature or forgery made without my knowledge and without my approval;

I did not participate in the negotiation of the check(s), draft(s) or other instrument(s);

I did not receive the proceeds of the check(s), draft(s) or other instrument(s);

This affidavit of forgery is made voluntarily and for the purpose of obtaining the proceeds of the check(s), draft(s) or other instrument(s) credited against my account;

The information I have regarding the forgery, how it may have occurred, and who may have participated in the making of the forgery, is as follows:

I will testify, declare, depose, or certify to the truth of any or all of the foregoing before any competent, court, tribunal, panel, officer or person and I will cooperate fully in the prosecution of the person or persons who forged the above-described check(s), draft(s) or other instrument(s).

Further affiant sayeth not.

____________________________________

(Signature line for the Affiant)

____________________________________

Subscribed and sworn to before me this ________ day of ___________________, __________.

(Notary Seal)

__________________________________________

(signature of notary public)

My commission expires:

___________________________________________

UCC ARTICLES 3 & 4 - NEGOTIABLE INSTRUMENTS - SAMPLE AFFIDAVIT OF FORGERY OR UNAUTHORIZED SIGNATURE ON A CHECK, DRAFT OR OTHER INSTRUMENT

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Nebraska Bankers Association

UCC ARTICLES 3 & 4 - NEGOTIABLE INSTRUMENTS - SAMPLE AFFIDAVIT OF FORGERY OR UNAUTHORIZED SIGNATURE ON A CHECK, DRAFT OR OTHER INSTRUMENT