State of Nebraska )
) ss.
County of Cornhusker )
I, (insert name here), being first duly sworn, do hereby depose and state that:
1. I am the person named as drawer of check number ____ drawn on account number _____
on the ____ day of _____, 20__.
2. The above identified check was drawn on (insert name of financial institution or entity); that said check was originally drawn in the amount of $ (insert dollar amount) payable to (insert name of payee); that said check was altered by a person or persons unknown to me (check and complete one or both):
____ changed the amount to $(dollar amount)
____ change the payee(s) to (insert changes made to payee(s))
3. I have received no benefit or value from the proceeds of the above described check, either directly or indirectly.
4. I have no knowledge or information concerning the indorsement or negotiation of the above-described check, (and if applicable, insert the following: “except as follows” with a description).
5. This affidavit of check alteration is made voluntarily and for the purpose of establishing the fact that the check identified above was altered.
6. 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 altered the above described check.
7. The information contained in this Affidavit is true.
____________________________________
(Signature line for the Affiant)
___________________________________
(Address of the Affiant)
Subscribed and sworn to before me this (insert date).
(Notary Seal)
(Signature of notary public)
My Commission expires on (insert date).