AFFIDAVIT OF FORGED ENDORSEMENT

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STATE OF __________________________ FUND: _____________________________
SS
COUNTY OF _________________________ WARRANT Nº.______________________

I, the undersigned, being the rightful owner of the overlisted STATE’s Warrant Nº. ______________
dated _________________, in the amount of ________________________________________ dollars, do
hereby certify that my name as signed on the back of the said warrant is a forgery, and/or that I have
not received nor endorsed the said warrant: neither have I been benefited in any way from the
proceeds therefrom.

By Signing Below, I certify that:

- I am competent and authorized to be making these statements.
- I am competent to handle my affairs.
- I am no person (e.g. statutory person, trust, corporation, public office, etc) but a private
non-lienable natural living flesh and blood human being dweller.

Without Prejudice U.C.C. 1-308, 3-419, All Rights Reserved

By: ©
Payee’s Signature Payee’s Mailing Address

Payee’s Printed Name City, State, Postal Code/Zip, Country

Payee’s Street Address Payee’s Phone Number

City, State, Postal Code/Zip, Country Title of PERSON signing affidavit

Witness if signed by “X”

Without Prejudice U.C.C. 1-308, 3-419, All Rights Reserved Without Prejudice U.C.C. 1-308, 3-419, All Rights Reserved

By: © By: ©
Signature Signature

Printed Name Printed Name

Street Address Street Address

City, State, Postal Code/Zip, Country City, State, Postal Code/Zip, Country

Subscribed and sworn before me this Gregorian ______ day of ____________________, 20____.

Witness/Notary Public in and for the above listed STATE Witness/Notary Public Residence

My Appointment Expires: