AFFIDAVIT A F
of Forged Endorsement/Signature, Alteration, Counterfeit or Unauthorized Remotely Created Check
CUSTOMER’S INFORMATION Name (Business or Individual):
Account Number:
Street Address: City:
State:
Home Phone:
Zip:
Business Phone:
DESCRIPTION OF DISPUTED ITEM (Select type of item, type of dispute and enter details) q Check/Substitute Check
q Remotely Created Check
q Forgery
q Counterfeit
q Alteration
Date:
q Other
Check/Serial #:
Drawer (i.e., maker):
Amount: $
Payable to the Order of:
CLAIM DESCRIPTION Check all that apply. The item(s) described above were improperly paid because of a(n):
q Drawer’s Signature Forged/Unauthorized The signature of
(drawer’s name) on the check or
withdrawal order is a forgery or is unauthorized. I did not sign, and I did not authorize the signature.
q Endorsement Forged/Unauthorized The endorsement of
(payee’s name) on the above check
is a forgery. I did not write or authorize the endorsement.
q Altered Amount The amount of the above check was altered from the original amount of $
to $
.
I did not alter the amount of the check and I did not authorize that it be altered. I received no part of the amount of the item in excess of the original amount, nor was any part of the excess amount applied to any use or purpose on my behalf.
q Altered Payee Name An unknown person altered the payee’s name order of
UPDATED 1/2024
on the check to make it payable to the . I did not alter the payee’s name and I did not authorize any alteration.
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