Fillable 11145 Affidavit Of Check Account Fraud 0416 EDIT

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11145 Affidavit Of Check Account Fraud 0416 EDIT

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Upon receipt of this completed packet, Kinecta Federal Credit Union
will research your claim. The Credit Union will resolve your claim within
10 business days or will contact you directly for additional information.
Please contact
800.854.9846
if you have additional questions
regarding your claim.
1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.4600 • www.kinecta.org
RETAILSERVICES
COMPLETING AN AFFIDAVIT OF CHECK / ACCOUNT FRAUD
GENERAL INFORMATION:
An Afdavit of Check / Account Fraud is required whenever any item drawn on your Kinecta Federal Credit Union
account (s) is fraudulently negotiated in any manner. This includes forging your signature on a check, deposit or
withdrawal receipt; forging your endorsement on the back of a check and/or any alteration of a check, deposit or
withdrawal receipt.
A timely completion of this Afdavit is important to the resolution of your claim.
We advise that you complete and return the Afdavit within 7 business days of reporting the fraud activity to
Kinecta Federal Credit Union to ensure a prompt resolution.
BEFORE you proceed with this claim, please be aware that a false declaration could subject you to criminal
prosecution for perjury. Once this claim is completed and presented to Kinecta, the Credit Union may provide it to
law enforcement agencies.
COMPLETING THE AFFIDAVIT:
Enclosed in this packet is a Kinecta Federal Credit Union Afdavit of Check / Account Fraud (“Afdavit”). All
pages of the document must be lled out completely, legible and in ink. Be sure to sign your name (as it appears
on your account) and date the document. A notarized signature is required on this document. If the original item
being claimed as forged / unauthorized / altered is in your possession, the original MUST be returned with the
completed Afdavit.
The enclosed Afdavit includes a return envelope. If you choose to submit the completed Afdavit and all
attachments to Kinecta by U.S. Mail, please use this envelope. Write your return address on the upper left hand
front corner of the envelope and ensure the envelope has the proper postage.
You may choose to return the completed Afdavit and all attachments directly to any Kinecta location. The
branch will forward the completed claim to the Investigations Department for processing.
Be sure to make a copy of the completed forms for your records.
1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.4600 • www.kinecta.org
AFFIDAVIT OF CHECK / ACCOUNT FRAUD
11145-06/16Page 1 of 3
RETAILSERVICES
MEMBER NAME KINECTA MEMBERSHIP NUMBER DATE
Signature Forged Endorsement
Forged
Counterfeit Altered Unauthorized
Draft
Other
My signature on the
face of the check(s)
listed below is a
forgery. I did not sign
the check(s) and I
did not authorize the
signature
My endorsement
on the back of the
check(s) listed below
is forged, missing,
or incorrectly
endorsed. I did
not sign the
check(s) and I did
not authorize the
signature(s)
The check(s)
are an imitation
of checks drawn
on my account.
I did not create,
sign or authorize
the creation or
signatures of the
checks listed below.
The check(s) below
have unauthorized
alterations. I did
not alter the payee
or the amount, nor
have I directly or
indirectly authorized
anyone to make
alterations to the
check(s).
I did not authorize or
approve the creation
or payment of this
item
Bill Pay
Withdrawal
Remotely
Created
Check
Non-receipt
of Funds
Over the Counter
Withdrawals
(Provide details of
transaction Below)
Please include the following information for each fraudulent check:
*If you have more than 3 checks to list please use the “Addendum to Afdavit of Check Fraud”
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CLAIM TOTAL:
Police Report Information (Case # / Police Department):
Suspect Information (if known):
1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.4600 • www.kinecta.org
AFFIDAVIT OF CHECK / ACCOUNT FRAUD
RETAILSERVICES
BY SIGNING BELOW, YOU ARE MAKING THE FOLLOWING DECLARATIONS:
• I did not receive any benet or value from the proceeds of the check(s) (or transactions) listed above.
• I have not arranged with the person(s) who misused the check(s) listed above to be reimbursed for any portion of the proceeds
of the check(s).
• I have not authorized anyone, either orally or in writing, to act on my behalf by writing, signing, endorsing or altering the items
in question.
• I will cooperate in any investigation, promptly disclose any information requested by Kinecta Federal Credit Union, and if necessary,
cooperate fully with any prosecution.
•I will testify to the truth of these statements in any legal case which may result from this afdavit.
I DECLARE UNDER THE PENALTY OF PERJURY THAT THE ABOVE STATED IS TRUE AND ACCURATE.
Member Signature (If a Business account, your Title) Date
Member Address Phone Number
PAYEE/ENDORSER SIGNATURE (FORGED ENDORSEMENT CLAIMS ONLY)
Signature of Payee/Endorser
(If a Business account, include your Title)
Date
THE STATE OF CALIFORNIA
COUNTY OF: _____________________________
Subscribed and sworn to (or afrmed) before me on this ____ day of _______________, 20___ by _____________________________
Proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.
Signature____________________________________________
Printed or Typed Name of Notary
____________________________________________________
My Commission Expires ________________________________
[seal]
CREDIT UNION USE ONLY
MSC / DEPT NAME /
NUMBER
REP NAME / TELLER # DATE MEMBERSHIP NUMBER OR SHARE TYPE CHANGED
YES NO
If NO, please explain
A notary public or other ofcer completing this certicate veries only the identity of the individual who signed the document to which this certicate is attached, and not the
truthfulness, accuracy, or validity of that document
11145-06/16Page 2 of 3
1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.4600 • www.kinecta.org
ADDENDUM TO AFFIDAVIT OF CHECK FRAUD
MEMBER NAME MEMBERSHIP NUMBER
TYPE OF FRAUD: FORGERY COUNTERFEIT
ALTERED UNAUTHORIZED DRAFT OTHER
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available:
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim):
TOTAL DOLLAR AMOUNT OF CHECKS LISTED ON THIS PAGE: $________________
I DECLARE UNDER THE PENALTY OF PERJURY THAT THE ABOVE STATED IS TRUE AND ACCURATE.
Member Signature (If a Business account, your Title) Date
Member Address Phone Number
PAYEE/ENDORSER SIGNATURE (FORGED ENDORSEMENT CLAIMS ONLY)
Signature of Payee/Endorser
(If a Business account, include your Title)
Date
THE STATE OF CALIFORNIA
COUNTY OF: _____________________________
Subscribed and sworn to (or afrmed) before me on this ____ day of _______________, 20___ by _____________________________
Proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.
Signature____________________________________________
Printed or Typed Name of Notary
____________________________________________________
My Commission Expires ________________________________
[seal]
AFFIDAVIT OF CHECK / ACCOUNT FRAUD
RETAILSERVICES
A notary public or other ofcer completing this certicate veries only the identity of the individual who signed the document to which this certicate is attached, and not the
truthfulness, accuracy, or validity of that document.
11145-06/16Page 3 of 3
1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.4600 • www.kinecta.org
RETAILSERVICES
Please follow the instructions below when completing the Afdavit. Each area on the sample
Afdavit has been numbered. The instruction numbers match the area of the sample Afdavit:
1. Member name: Please enter your complete name as it appears on your account with
Kinecta Federal Credit Union.
2. Kinecta Membership Number: Enter the account number involved in the claim. You will
be required to complete a separate Afdavit for each account, if more than one account is
involved.
3. Date: Enter today’s date.
1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.4600 • www.kinecta.org
AFFIDAVIT OF CHECK / ACCOUNT FRAUD
17262-03/15Page 1 of 3
RETAILSERVICES
MEMBER NAME KINECTA MEMBERSHIP NUMBER DATE
Signature Forged Endorsement
Forged
Counterfeit Altered Unauthorized
Draft
Other
My signature on the
face of the check(s)
listed below is a
forgery. I did not sign
the check(s) and I
did not authorize the
signature
My endorsement
on the back of the
check(s) listed below
is forged, missing,
or incorrectly
endorsed. I did
not sign the
check(s) and I did
not authorize the
signature(s)
The check(s)
are an imitation
of checks drawn
on my account.
I did not create,
sign or authorize
the creation or
signatures of the
checks listed below.
The check(s) below
have unauthorized
alterations. I did
not alter the payee
or the amount, nor
have I directly or
indirectly authorized
anyone to make
alterations to the
check(s).
I did not authorize or
approve the creation
or payment of this
item
Bill Pay
Withdrawal
Remotely
Created
Check
Non-receipt
of Funds
Over the Counter
Withdrawals
(Provide details of
transaction Below)
Please include the following information for each fraudulent check:
*If you have more than 3 checks to list please use the “Addendum to Afdavit of Check Fraud”
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CLAIM TOTAL:
Police Report Information (Case # / Police Department):
Suspect Information (if known):
1 2 3
1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.4600 • www.kinecta.org
RETAILSERVICES
Select type of fraud involved:
4. Signature Forged: Select this box if your signature on the face (front) of the check(s)
listed in the Afdavit was forged and you did not sign or authorize the signing of the item(s)
in question.
5. Endorsement Forged: Select this box if the check if your endorsement of the back of the
check(s) listed in the claim was forged, missing or incorrectly endorsed and your neither
signed or authorized the signing of the item(s) in question.
6. Counterfeit: Select this box if the check(s) listed in the claim are an imitation of the
legitimate checks drawn on your account and you did not create, sign or authorize the
creation of the item in question.
7. Altered: Select this box if the check(s) listed in the claim have unauthorized alterations,
specically if the payee or the amount has been altered without your direct or indirect
authorization.
8. Unauthorized Draft: Select this box if an unauthorized payment in form of a Bill Pay
Withdrawal or a Remotely Created check (Electronic Draft) was negotiated against your
account.
9. Other: Select” Non-receipt of Funds” if an electronic draft payment was issued from your
account but not received and negotiated by the intended company/debtor. Select “Over the
Counter Withdrawals” if an unauthorized cash or check withdrawal was performed against
your account at a branch facility.
1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.4600 • www.kinecta.org
AFFIDAVIT OF CHECK / ACCOUNT FRAUD
17262-03/15Page 1 of 3
RETAILSERVICES
MEMBER NAME KINECTA MEMBERSHIP NUMBER DATE
Signature Forged Endorsement
Forged
Counterfeit Altered Unauthorized
Draft
Other
My signature on the
face of the check(s)
listed below is a
forgery. I did not sign
the check(s) and I
did not authorize the
signature
My endorsement
on the back of the
check(s) listed below
is forged, missing,
or incorrectly
endorsed. I did
not sign the
check(s) and I did
not authorize the
signature(s)
The check(s)
are an imitation
of checks drawn
on my account.
I did not create,
sign or authorize
the creation or
signatures of the
checks listed below.
The check(s) below
have unauthorized
alterations. I did
not alter the payee
or the amount, nor
have I directly or
indirectly authorized
anyone to make
alterations to the
check(s).
I did not authorize or
approve the creation
or payment of this
item
Bill Pay
Withdrawal
Remotely
Created
Check
Non-receipt
of Funds
Over the Counter
Withdrawals
(Provide details of
transaction Below)
Please include the following information for each fraudulent check:
*If you have more than 3 checks to list please use the “Addendum to Afdavit of Check Fraud”
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CLAIM TOTAL:
Police Report Information (Case # / Police Department):
Suspect Information (if known):
4 5 76 8 9
1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.4600 • www.kinecta.org
Please provide a description of the item(s) involved:
10. Check Number: Enter the check number to be included in the claim. If there is more
than one item in the claim, list each check on a separate line.
10a. If the item is altered, use the space beneath to provide details of the originally issued
item, including the check number, amount, payee and issue date. For altered claims,
please provide a copy of the carbon of the check with the claim.
If the claim includes more than three items. List the reminder of the checks on the “Addendum
to Afdavit of Check Fraud”
11. Date: Enter the date of the check as it appears on the item. If the claim is for
unauthorized Over the Counter Withdrawal, enter the date of the transaction.
12. Amount: Enter the dollar amount of the item paid against the account.
13. Made Payable To: Enter the information written in the “Payable To” line of the item paid
against the account.
14. Claim Total: Enter the total amount of the checks/transactions listed.
RETAILSERVICES
1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.4600 • www.kinecta.org
AFFIDAVIT OF CHECK / ACCOUNT FRAUD
17262-03/15Page 1 of 3
RETAILSERVICES
MEMBER NAME KINECTA MEMBERSHIP NUMBER DATE
Signature Forged Endorsement
Forged
Counterfeit Altered Unauthorized
Draft
Other
My signature on the
face of the check(s)
listed below is a
forgery. I did not sign
the check(s) and I
did not authorize the
signature
My endorsement
on the back of the
check(s) listed below
is forged, missing,
or incorrectly
endorsed. I did
not sign the
check(s) and I did
not authorize the
signature(s)
The check(s)
are an imitation
of checks drawn
on my account.
I did not create,
sign or authorize
the creation or
signatures of the
checks listed below.
The check(s) below
have unauthorized
alterations. I did
not alter the payee
or the amount, nor
have I directly or
indirectly authorized
anyone to make
alterations to the
check(s).
I did not authorize or
approve the creation
or payment of this
item
Bill Pay
Withdrawal
Remotely
Created
Check
Non-receipt
of Funds
Over the Counter
Withdrawals
(Provide details of
transaction Below)
Please include the following information for each fraudulent check:
*If you have more than 3 checks to list please use the “Addendum to Afdavit of Check Fraud”
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CLAIM TOTAL:
Police Report Information (Case # / Police Department):
Suspect Information (if known):
10
10a
11 13
14
12
1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.4600 • www.kinecta.org
RETAILSERVICES
15. Police report Information: if a police report has been lled, enter the case number and
the name of the police department where it was lled.
16. Suspect Information: if you know, suspect someone who is responsible for or who
knows about the fraudulent activity, enter name(s), address(es) and phone number(s). If
you don’t have this information enter “I don’t know”.
1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.4600 • www.kinecta.org
AFFIDAVIT OF CHECK / ACCOUNT FRAUD
17262-03/15Page 1 of 3
RETAILSERVICES
MEMBER NAME KINECTA MEMBERSHIP NUMBER DATE
Signature Forged Endorsement
Forged
Counterfeit Altered Unauthorized
Draft
Other
My signature on the
face of the check(s)
listed below is a
forgery. I did not sign
the check(s) and I
did not authorize the
signature
My endorsement
on the back of the
check(s) listed below
is forged, missing,
or incorrectly
endorsed. I did
not sign the
check(s) and I did
not authorize the
signature(s)
The check(s)
are an imitation
of checks drawn
on my account.
I did not create,
sign or authorize
the creation or
signatures of the
checks listed below.
The check(s) below
have unauthorized
alterations. I did
not alter the payee
or the amount, nor
have I directly or
indirectly authorized
anyone to make
alterations to the
check(s).
I did not authorize or
approve the creation
or payment of this
item
Bill Pay
Withdrawal
Remotely
Created
Check
Non-receipt
of Funds
Over the Counter
Withdrawals
(Provide details of
transaction Below)
Please include the following information for each fraudulent check:
*If you have more than 3 checks to list please use the “Addendum to Afdavit of Check Fraud”
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CLAIM TOTAL:
Police Report Information (Case # / Police Department):
Suspect Information (if known):
15
16
1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.4600 • www.kinecta.org
RETAILSERVICES
17. Declaration and Notarized Signature: The Afdavit must be notarized, whether it
has been completed in a local Kinecta branch, or is being sent through the mail. This
document must be complete and must contain any supporting documentation. The
Addendum must be signed and notarized as well, if attached.
18. Payee/Endorser: If the claim involves a forged endorsement item, the true and intended
payee must sign and date the document in front of a notary.
19. This section is for Credit Union Use ONLY.
1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.4600 • www.kinecta.org
AFFIDAVIT OF CHECK / ACCOUNT FRAUD
RETAILSERVICES
BY SIGNING BELOW, YOU ARE MAKING THE FOLLOWING DECLARATIONS:
• I did not receive any benet or value from the proceeds of the check(s) (or transactions) listed above.
• I have not arranged with the person(s) who misused the check(s) listed above to be reimbursed for any portion of the proceeds
of the check(s).
• I have not authorized anyone, either orally or in writing, to act on my behalf by writing, signing, endorsing or altering the items
in question.
• I will cooperate in any investigation, promptly disclose any information requested by Kinecta Federal Credit Union, and if necessary,
cooperate fully with any prosecution.
•I will testify to the truth of these statements in any legal case which may result from this afdavit.
I DECLARE UNDER THE PENALTY OF PERJURY THAT THE ABOVE STATED IS TRUE AND ACCURATE.
Member Signature (If a Business account, your Title) Date
Member Address Phone Number
PAYEE/ENDORSER SIGNATURE (FORGED ENDORSEMENT CLAIMS ONLY)
Signature of Payee/Endorser
(If a Business account, include your Title)
Date
THE STATE OF CALIFORNIA
COUNTY OF: _____________________________
Subscribed and sworn to (or afrmed) before me on this ____ day of _______________, 20___ by _____________________________
Proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.
Signature____________________________________________
Printed or Typed Name of Notary
____________________________________________________
My Commission Expires ________________________________
[seal]
CREDIT UNION USE ONLY
MSC / DEPT NAME /
NUMBER
REP NAME / TELLER # DATE MEMBERSHIP NUMBER OR SHARE TYPE CHANGED
YES NO
If NO, please explain
A notary public or other ofcer completing this certicate veries only the identity of the individual who signed the document to which this certicate is attached, and not the
truthfulness, accuracy, or validity of that document
17262-03/15Page 2 of 3
17
18
19
1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.4600 • www.kinecta.org
RETAILSERVICES
20. AddendumtoAfdavit: This page is to be used if your claim involves multiple items
that have been forged, altered and/or unauthorized in the same manner (i.e., ve checks
each having the same forged maker’s signature on them).
Please ll all the information requested. Enter each additional claimed item on it’s own
line. Add the dollar amount of all items and write the total in the space provided. Sign and
date the Addendum in the spaces are the bottom. This form must also be notarized. If the
Addendum is used in your claim, it must be included withy the afdavit and all other supporting
documentation in the envelope provided by Kinecta Federal Credit Union.
1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.4600 • www.kinecta.org
ADDENDUM TO AFFIDAVIT OF CHECK FRAUD
MEMBER NAME MEMBERSHIP NUMBER
TYPE OF FRAUD:
FORGERY COUNTERFEIT
ALTERED UNAUTHORIZED DRAFT OTHER
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available:
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim if available):
CHECK# DATE AMOUNT MADE PAYABLE TO (TRANSACTION INFORMATION)
If this check is ALTERED, please provide details in the box below of the originally issued item - check #, Amount, Payee, Issue Date
(include the carbon copy of check with claim):
TOTAL DOLLAR AMOUNT OF CHECKS LISTED ON THIS PAGE: $________________
I DECLARE UNDER THE PENALTY OF PERJURY THAT THE ABOVE STATED IS TRUE AND ACCURATE.
Member Signature (If a Business account, your Title) Date
Member Address Phone Number
PAYEE/ENDORSER SIGNATURE (FORGED ENDORSEMENT CLAIMS ONLY)
Signature of Payee/Endorser
(If a Business account, include your Title)
Date
THE STATE OF CALIFORNIA
COUNTY OF: _____________________________
Subscribed and sworn to (or afrmed) before me on this ____ day of _______________, 20___ by _____________________________
Proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.
Signature____________________________________________
Printed or Typed Name of Notary
____________________________________________________
My Commission Expires ________________________________
[seal]
AFFIDAVIT OF CHECK / ACCOUNT FRAUD
RETAILSERVICES
A notary public or other ofcer completing this certicate veries only the identity of the individual who signed the document to which this certicate is attached, and not the
truthfulness, accuracy, or validity of that document.
17262-03/15Page 3 of 3
20
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11145 Affidavit Of Check Account Fraud 0416 EDIT

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Completed 7 September 2021

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