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Get Affidavit Of Forgery Form

AFFIDAVIT OF FRAUD AND FORGERY Debit Card Account Number Ending Debit Card Number please check one box Lost Never received in mail Stolen A police report was filed Report Police Agency Badge I have not used the above debit card for the purchase of merchandise services cash advances on the sales listed below. I have not authorized anyone else orally or in writing nor have I given consent nor do I have knowledge of implied consent to use or have possession of this debit card. I have not and will not receive goods services or otherwise benefit directly or indirectly from the fraudulent transactions listed below. I further agree that any information relating to the unauthorized use of this account may be provided to any investigative or prosecutorial agency. I have examined the following list of transactions Merchant Sale s Cash Advance s Cash Machine Advance s Statement Charges. Date Amount Merchant The total fees to be refunded The above identified transaction s were not made by me or by anyone acting upon my authority or with my consent or knowledge. I have no knowledge of the identity or whereabouts of the person s using the Debit Card. I can identify the suspect as Address Name Relationship City State Zip Phone I certify that no one was given my Personal Identification Number PIN if applicable with the exception of whose relationship to me is. In the event he/she is required to do so affiant states that he/she will appear as a witness in court to testify as to the facts stated above. NOTICE Any person who knowingly and with intent to injure defraud or deceive any insurance company submits a statement of claim containing any false or misleading information commits a crime. I swear this affidavit is true and understand that making a false sworn statement is subject to federal and/or state statutes and may be punishable by fines and/or imprisonment. I have not authorized anyone else orally or in writing nor have I given consent nor do I have knowledge of implied consent to use or have possession of this debit card. I have not and will not receive goods services or otherwise benefit directly or indirectly from the fraudulent transactions listed below. I have not and will not receive goods services or otherwise benefit directly or indirectly from the fraudulent transactions listed below. I further agree that any information relating to the unauthorized use of this account may be provided to any investigative or prosecutorial agency. I further agree that any information relating to the unauthorized use of this account may be provided to any investigative or prosecutorial agency. I have examined the following list of transactions Merchant Sale s Cash Advance s Cash Machine Advance s Statement Charges. I have examined the following list of transactions Merchant Sale s Cash Advance s Cash Machine Advance s Statement Charges. Date Amount Merchant The total fees to be refunded The above identified transaction s were not made by me or by anyone acting upon my authority or with my consent or knowledge.

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