You may complete this form online and print to sign and fax or mail as indicated above.
1. I am first duly sworn and state I am:
Name
Account Number
Mailing Address
City, State, Zip
Phone Number: Home Work
2.
The instrument(s) forged is/are a: (Check the appropriate box)
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)
Date
Instrument Number
Dollar Amount
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 signature is a forgery.
7.
Do you know who forged your signatures?
If yes, provide details on a separate page or the back of this page.
Yes No
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:
______________________________________________________________________________________
Check
Share Draft
Other (Specify)
Cash Withdrawal
Loan Note (including Co-maker forgery)
Maker (on note or face of share draft/check)
Co-maker (on a loan)
Other (Specify)
5.
This signature for the instrument listed below and attached to this affidavit is not written nor authorized by me and is
a forgery:
Payee/Endorser (on back of check/share draft or bottom of withdrawal voucher)
Santa Clara, CA 95051
2805 Bowers Ave
AFFIDAVIT OF FORGERY
Email To: DisputeForm@keypointcu.com
Fax To: (408) 731-4068
OR
