Affidavit of Forgery
Each authorized user must complete a separate Affidavit form.
Form Instructions
Complete, print, sign and mail this form to :
Star One Credit Union
Attn: Support Services
P.O. Box 3643
Sunnyvale CA 94088-3643
This form must be notarized.
Each authorized user must complete a separate Affidavit form.
Your Information
STATE OF CALIFORNIA, COUNTY OF Santa Clara, (Affiant's Name) , being first duly sworn, deposes and says:
That there was charged to the affiant's account at the Star One Credit Union the check/share withdrawal/share draft purporting to be signed by affiant as maker, described in the following schedule:
| Check/ Withdrawal # |
Dated (mm/dd/yyyy) |
Amount $ | Payee | Endorsements (if any) |
|---|---|---|---|---|
| 1. | ||||
| 2. | ||||
| 3. | ||||
| 4. |
That affiant received no benefit or value from the proceeds of any said checks/withdrawals/share draft and that no part of any said checks/withdrawals/share drafts was applied to any use or purpose in affiant's behalf.
That this affidavit is made for the purpose of having Star One Credit Union reimburse affiant for the amount of said checks/withdrawals/share drafts.
That affiant will testify, declare, depose or certify to the truth of each and all of the foregoing before any competent tribunal, officer or person, in any case now pending or that may be hereafter instituted in connection with the matters contained in this affidavit.
| ___________________________________________ Affiant's Signature |
| : | |
State of , County of . Subscribed and sworn (or affirmed) before me on this day of , 20 , by , proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.
| ___________________________________________ Signature of Notary Public |
Note: If additional space is needed to explain your circumstances, please use the back of the form.