STATE OF ----------)
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.
Sworn to before me this [dated]