) s.s.:

COUNTY OF ---------)

The undersigned, being duly sworn, deposes and says:

I am over the age of eighteen years and, on [date], was and still am a depositor in [bank] at its [address] office.

That on [date], only I was authorized to draw checks on or indorse checks to [bank] on my account number [number].

I have examined the signature "[name]" of check number [number] dated [date] purported to be drawn by me on [bank] and hereby state: that I did not write or authorize to be written this signature.

The signature is a forgery and was made by someone unknown to Affiant.

The purpose of this Affidavit is to induce [bank] to credit my account number [number] in the amount of this check.

[signature]

Affiant

Sworn to before me this [dated]

[signature]

Notary Public