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Print Application!

1. I am first duly sworn and state I am:
   
   Name______________________________________________________
   
   Mailing Address________________________________________________
   
   City, State, Zip_________________________________________________
   
   Phone Number Home (_______) ____________ Work (_______) ___________
   
   



2. The instrument(s) forged is/are a: (Check the appropriate box)

   Check	Cash Withdrawal Voucher
   Share Draft	Loan Note (including Co-maker forgery)
   Other (specify) _____________________________________________ Name of Credit Union or Bank




3. The instrument(s) is/are drawn on ______________________________________




4. On the instrument(s) I am named as the: (Check the appropriate box)
   Payee/endorser (on back of check/share draft or bottom of withdrawal voucher)
   Maker (on note or face of share draft/check)
   Co-maker (on loan)
   Other (specify) __________________________________________________________________



5. This signature for each instrument(s) listed below and attached to this affidavit is not written nor authorized by me and is a forgery:

   Date	Instrument Number	Dollar Amount
   a) ______________________	______________________	______________________
   b) ______________________	______________________	______________________
   c) ______________________	______________________	______________________
   (if more space is required, use a separate sheet)




6. I did not receive any part of the proceeds of the instrument(s) listed above. This affidavit is made voluntarily for the purpose of establishing the fact that my signature is a forgery.



7. Do you know who forged your signatures? Yes No If yes, provide details on a separate page or the back of this page.



8. I understand this forgery is subject to investigation by local, state and/or federal law enforcement agencies. I may be required to comply with a court order or subpoena to give testimony.



9. I understand making a false sworn statement is subject to federal and/or state statutes and may be punishable by fines and/or by imprisonment.




Sign your name five times:	_______________________________________________________________
	_______________________________________________________________
	_______________________________________________________________
	_______________________________________________________________
	_______________________________________________________________

State of ______________________________________	County of ___________________________________
Subscribed and sworn to before me this ___________	day of ___________________,__________
________________________________________________	Notary