State of Nebraska )
) ss.
County of Cornhusker )
I, (insert name here), being first duly sworn, do hereby depose and state that:
For Individuals:
1. I am the person named as (insert status of person, e.g., “Payee”, “Drawer” or “Indorser”) in the (insert appropriate description, e.g., “check” or “instrument”) attached to this affidavit, identified as (insert identifying features, e.g., number of instrument, date of instrument, drawn on the name of the financial institution or entity, drawn by the name of the person or entity, payable to the order of the person or entity, for the specified dollar and cent amount).
For General or Limited Partnerships, including Limited Liability Partnerships:
1. I am a partner of (insert name of partnership), named as (insert status of partner, e.g., “Payee”, “Drawer” or “Indorser”) in the (insert appropriate description, e.g., “check” or “instrument”) attached to this affidavit, identified as (insert identifying features, e.g., number of instrument, date of instrument, drawn on the name of the financial institution or entity, drawn by the name of the person or entity, payable to the order of the person or entity, for the specified dollar and cent amount).
For Incorporated Entities, including Limited Liability Companies:
1. I am the (insert the office title or other title of official capacity in the corporation), of (insert the name of the incorporated entity), named as (insert status of incorporated entity, e.g., “Payee”, “Drawer” or “Indorser”) in the (insert appropriate description, e.g., “check” or “instrument”), identified as (insert identifying features, e.g., number of instrument, date of instrument, drawn on the name of the financial institution or entity, drawn by the name of the person or entity, payable to the order of the person or entity, for the specified dollar and cent amount).
2. The indorsement of (insert name of person or entity) on the above described (insert appropriate description, e.g., “check” or “instrument”) was not authorized, is a forgery and was made without my knowledge or consent.
3. (Insert name of person, partnership or incorporated entity) has received no benefit or value from the proceeds of the above described (insert appropriate description, e.g., “check” or “instrument”), either directly or indirectly.
4. I have no knowledge or information concerning the indorsement or negotiation of the above-described (insert appropriate description, e.g., “check” or “instrument”), (and if applicable, insert the following: “except as follows” with a description).
5. The amount of the (insert appropriate description, e.g., “check” or “instrument”) is due and owing to (insert name of person or entity here).
6. This affidavit of forgery is made voluntarily and for the purpose of obtaining the proceeds of the above-described (insert appropriate description, e.g., “check” or “instrument”) and establishing the fact of forgery.
7. 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 (insert appropriate description, e.g., “check” or “instrument”).
8. 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).