Affidavit of Check Forgery

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 or Withdrawal 1:

Check or Withdrawal 2:

Check or Withdrawal 3:

Check or Withdrawal 4:

That the purported signature of affiant on each of said checks/withdrawals/share drafts is a forgery; that none of said checks/withdrawals/share drafts was signed or issued by affiant or by any person authorized by affiant to sign same; that affiant has no knowledge or information respecting the circumstances under which any of said checks/withdrawals/share drafts was signed or issued or the persons who signed same except (enter 400 characters maximum):

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.

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Affiant's Signature

proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.

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Signature of Notary Public

Note: If additional space is needed to explain your circumstances, please use the back of the form.

Star One Credit Union use only