AFFIDAVIT OF FORGERY

State of________________________

County of______________________


I, _________________________________, being first duly sworn, depose and say as follows:

1. That I have examined the attached check drawn on ______________

____________________________________________________ dated__________________, on account

number______________, in the sum of_____________.

2. Deponent further states:

That the signature as drawer on the above-described check was not made by deponent nor was it placed upon said check with the knowledge or consent of deponent and deponent has not benefited in any way by issuance of negotiation of said check.

______________________________
SIGNATURE

______________________________
NAME

______________________________
ADDRESS

______________________________
CITY, STATE, AND ZIP CODE



Subscribed and sworn to me this______day of _____________20____

_______________________________
NOTARY PUBLIC SIGNATURE

State of _________________________

My Commission Expires_____________ (SEAL)