Please contact if you have additional questions regarding your claim.

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Upon receipt of this completed packet, Kinecta Federal Credit Union will research your claim. The Credit Union will resolve your claim within 10 business days or will contact you directly for additional information.

Please contact 800.854.9846 if you have additional questions regarding your claim.

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FORGERY AFFIDAVIT CLAIM

BEFORE Y O U M A K E THIS CLAIM ...

PLEASE BE AWARE THAT A FALSE DECLARATION COULD SUBJECT YOU TO CRIMINAL PROSECUTION FOR PERJURY. FILING THIS DECLARATION MEANS THAT KINECTA FEDERAL CREDIT UNION MAY PROVIDE ANY OF THIS INFORMTION TO LAW ENFORCEMENT AGENCIES.

MEMBER S NAME: KINECTA MEMBERSHIP NUMBER:

ADDRESS/CITY/STATE/ZIP:

DAYTIME PHONE #: EVENING PHONE #:

■

■ CHECK OR DRAFT # ■■ ^DEPOSIT ■■ ^WITHDRAWAL

DRAWN ON (NAME OF INSTITUTION)

DATE OF ITEM: DRAWN BY:

AMOUNT $ PAYABLE TO:

DATE PAID: ENDORSED BY: PAID BY: (BANK, BRANCH NAME & #)

D E C L A R ATION:

You may initial more than one claim below if this item has been misused in more than one way. For example, someone altered the payee s name and raised the dollar amount.

If the claim involves more than one check that was misused in the same way, complete the Forgery Affidavit Claim for the first check and use the Addendum to Forgery Affidavit Claim form to list the remaining checks. Any such completed, signed Addendum to the Forgery Affidavit Claim form is incorporated herein by reference.

My purported signature/endorsement appears on the item described above. I have carefully examined it and hereby state:

______ Maker Signature Forged/Unauthorized SignatureI did not sign, authorize, or otherwise approve the signature on the above referenced check, withdrawal, deposit or deposit item.

______ Endorsement ForgedI did not endorse, authorize, or otherwise approve the endorsement on the back of the above referenced check.

______ Altered Check, Withdrawal, Deposit Slip or Deposited ItemThe above referenced checks, withdrawal, deposit slip or deposited item was altered as follows:

______________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________I also declare that by my initials below, I agree to the following:

______ I did not receive any benefit or value from the proceeds of the check, withdrawal, deposit, or deposited item nor were any proceeds applied to any use or purpose on my behalf, and

______ I have not arranged with the person(s) who misused the item to be reimbursed for any proceeds of check, withdrawal, deposit or deposited item, and

______ I promise to testify or certify to the truth of applicable statements in this Declaration before any competent judge, officer of the court, or other person, in any case now pending or which may occur regarding this Declaration.

I believe the forgery of my name was made by _____________________________ who resides at ________________

_________________________. I am making this statement voluntarily. I am willing to give further testimony about this matter, as requested by Kinecta Federal Credit Union. I swear under penalty of perjury under the laws of this state that the foregoing is true and correct. My signature below has been witnessed by a notary public as certified below.

MEMBER SIGNATURE DATE PLACE NOTARY STAMP HERE

NOTARY SIGNATURE DATE

THIS NOTARIZATION STAMP IS FOR BOTH SIDES OF THIS DOCUMENT

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FORGERY AFFIDAVIT CLAIM

1. Will you cooperate in the prosecution of person(s) responsible, including testifying in court? ■■ Yes ■■ No

2. Have you carefully examined all of the items in question? ■■ Yes ■■ No

3. How did the forger/unauthorized signer get possession of your items?

________________________________________________________________________________________________________________________

4. Have you ever authorized anyone on your behalf, either orally or in writing, to sign, endorse or alter said item?

________________________________________________________________________________________________________________________

5. When did you become aware that forged/unauthorized items were paid on your account and what action(s)

did you take, if any?________________________________________________________________________________

6. If checks are involved, did you have your checkbook on the date the item was written? ■■ Yes ■■ No On the date the forgery was discovered? ■■ Yes ■■ No

Is the checkbook in your possession now? ■■ Yes ■■ No

7. Have you reported the stolen/forged/unauthorized item(s) to the police? Yes No

If yes: Name of law enforcement agency ________________________________ Case number __________________

8. Please list all checks missing or unaccounted for ________________________________________________________

________________________________________________________________________________________________________________________

9. State all circumstances surrounding the theft/loss of unauthorized use of your items ____________________________

________________________________________________________________________________________________________________________

10. Do you know or suspect any person(s) who may have committed the theft/unauthorized use? ■■ Yes ■■ No If yes, who? ______________________________________________________________________________________

Has this person previously signed your name on any checks or other item? ■■ Yes ■■ No

If yes, describe the circumstances, including when. _______________________________________________________

________________________________________________________________________________________________________________________

11. Is the forger/unauthorized signer employed by you and responsible for balancing or reconciling your accounts?

■

■ Yes ■■ No If yes, who and how can they be contacted? __________________________________________

________________________________________________________________________________________________________________________

ADDITIONA L M E M B E R I N F O R M ATION:

PLEASE PROVIDE US WITH THE FOLLOWING INFORMATION TO ASSIST US IN OUR INVESTIGATION. INCLUDE ANY NAMES OF INDIVIDUALS YOU BELIEVE MAY BE INVOLVED AND CONTACT INFORMATION, INCLUDING ADDRESSES, PHONE NUMBERS, ETC. IF YOU CONTACTED A POLICE DEPARTMENT TO MAKE A CLAIM, PLEASE INCLUDE THE NAME AND LOCATION OF THAT DEPARTMENT, THE OFFICER WHO TOOK

THE REPORT AND THE REPORT NUMBER.

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FORGERY AFFIDAVIT CLAIM

12. Are you aware of any other pertinent information not included in this document? ■■ Yes ■■ No

If yes, describe what it is. ______________________________________________________________________________________________

________________________________________________________________________________________________________________________

13. Has this or a similar situation happened to you before? ■■ Yes ■■ No

If yes, describe what happened and any suspects involved. ____________________________________________________________

________________________________________________________________________________________________________________________

14. Have you received reimbursement from any source? ■■ Yes ■■ No

If yes, please provide details ________________________________________________________________________

________________________________________________________________________________________________________________________

I swear under penalty of perjury under the laws of this state that the foregoing is true and correct.

My signature below has been witnessed by a notary public as certified on reverse.

MEMBER S SIGNATURE DATE

Please sign your name five times:

______________________________________________________________________________________

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FORGERY AFFIDAVIT CLAIM

(A) It is unlawful to:

1. Knowingly present or cause to be presented any false or fraudulent claim for the payment of a loss, including payment of a loss under a contract of insurance;

2. Knowingly present multiple claims for the same loss or injury, including presentation of multiple claims to more than one insurer, with an intent to defraud;

3. Knowingly cause or participate in a vehicular collision, or any other vehicular accident, for the purpose of presenting any false or fraudulent claim;

4. Knowingly prepare, make or subscribe any writing, with intent to present or use the same, or to allow it to be presented in support of any such claims.

(B) Every person who violates any provision of this section is punishable by imprisonment in the state prison, for two, three or five years, or by fine not exceeding twenty-five thousand dollars ($25,000), or by both.

"FOR Y O U R P RO T E C T I O N,

CALIFORNIA LAW R E QUIRES THE FOLLO WING TO APPEAR ON THIS FORM:"

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This addendum is to be used only if the member has multiple items that have been forged, altered, or unauthorized in the same manner.

MEMBER NAME BRANCH NAME & NO.

PAID BY (BANK OR BRANCH NAME) CHECK NO. ITEM DATE DATE PAID AMOUNT PAYABLE TO

Total dollar amount of checks listed:

$

I declare that the foregoing statement is true and correct. My signature below has been guaranteed by a Notary Public as certified below.

___________________

Member Signature Date Signed

THIS FORM MUST BE ATTACHED TO THE KINECTA FORGERY/ALTERED CHECK AFFIDAVIT CLAIM.

FAILURE TO COMPLETE, SIGN AND DATE BOTH OF THESE DOCUMENTS COULD MEAN A DELAY IN PROCESSING YOUR CLAIM.

MEMBER SIGNATURE DATE PLACE NOTARY STAMP HERE

NOTARY SIGNATURE DATE

ADDENDUM TO FORGERY AFFIDAVIT CLAIM

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COMPLETING A FORGERY AFFIDAVIT CLAIM

General Information:

An Affidavit of Forgery Claim is required whenever any item drawn on your Kinecta Federal Credit Union account(s) is fraudulently negotiated in any manner. This includes forging your signature on a check, deposit or withdrawal receipt; forging your

endorsement on the back of a check and/or any alteration of a check, deposit or withdrawal receipt. A timely completion of this Affidavit is important to the resolution of your claim. It is advisable to complete and return the affidavit within 7 business days to ensure a prompt resolution.

BEFORE you proceed with this claim, please be aware that a false declaration could subject you to criminal prosecution for perjury. Once this claim is completed and presented to Kinecta, the Credit Union may provide it to law enforcement agencies.

Completing the Affidavit of Forgery:

Enclosed in this packet is a Kinecta Federal Credit Union Affidavit of Forgery Claim.

Both sides of the claim must be filled out completely in ink. Please write legibly. Be sure to sign your full name (as it appears on your account) and date on the front and back. A notarized signature is required on this document. If the original item being claimed as forged/unauthorized/altered is in your possession, the original MUST be returned with the completed Affidavit of Forgery Claim.

The enclosed Affidavit of Forgery Packet includes a return envelope. If you choose to submit the completed affidavit and all attachments to Kinecta by U.S. Mail, please use this envelope. Please place your return address on the upper left hand front corner of the envelope and ensure the envelope has the proper postage.

You may choose to return the completed Affidavit of Forgery Claim and all attachments directly to any Kinecta location using the enclosed envelope. The branch will forward the completed claim to Loss Prevention/Recovery for processing.

Please make a copy of the completed forms for your records.

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Please follow the instructions below when completing the Affidavit of Forgery Claim.

Each area on the sample affidavit has been numbered. The instruction numbers match the area on the sample affidavit:

1. Member Name: Please enter your complete name as it appears on your account with Kinecta Federal Credit Union.

2. Kinecta Membership Number: Enter the account number involved in the claim.

You will be required to complete a separate Affidavit of Forgery Claim for each account, if more than one account is involved.

3. Address/City/State/ZIP: Enter your complete address, including a suite or apartment number, and zip code.

4. Daytime Phone: Enter the phone number (including area code) where you can be reached between 9 a.m. and 5 p.m., Monday through Friday.

5. Evening Phone: Enter the phone number (including area code) where you can be reached in the evening.

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Check or Draft No: If the item involved in the claim is a check or draft, place an ‘X’ in the box and enter the check/draft number of the item. If there is more than one item in the claim and these items have all been forged/altered/unauthorized, list one check or draft number and list the remainder of the checks on the Addendum To Affidavit of Forgery Claim enclosed in this packet.

If you have several checks/drafts in your claim and each has been

forged/altered/unauthorized in a different way (i.e. different forged signatures on the items), you must complete a separate Affidavit of Forgery Claims for each fraudulent occurrence.

Note: Only the member whose signature has been forged can sign the Affidavit of Forgery Claim.

6a. Deposit

If the item involved in the claim is a forged/altered signature on a Kinecta deposit, place an ‘X’ in the box. Please read #6 (above) if there are multiple deposits in your claim.

6b. Withdrawal

If the item involved in the claim is a forged/altered signature on a Kinecta withdrawal, place an ‘X’ in the box. Please read #6 (above) if there are multiple withdrawals in your claim.

7. Drawn On: Enter the name of the financial institution (bank, savings association, credit union) that maintains the account against which this check is drawn.

8. Date of Item: Enter the date that appears on the item.

9. Drawn By (Issued By): Enter the full name of the individual(s) or company/organization that issued the item.

10. Dollar Amount: Enter the amount for which the item was written. If the check was altered, enter the altered amount.

11. Payable To: Enter the information written in the ‘Payable To’ line of the item. If the check was altered, enter the altered payee’s name.

12. Date Paid: Enter the date that the item was paid/negotiated. If the item is a

check/draft, there should be a stamped date on the back. If the item is a deposit or withdrawal, enter the date on the front of the receipt.

13. Endorsed By: If the item is a check/draft, enter the name of the person or entity that endorsed (signed) on the back. If the fraudulent item is a deposit or withdrawal, enter

‘N/A’ on this line.

14. Paid By (Bank, Branch name and No.): Enter the financial institution’s name where the item was paid/deposited/cashed. Include the branch name and number, if shown.

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15. Declaration: Please read this paragraph carefully. Below the paragraph are three possible choices. Depending on the type of fraud involved, you could claim one, two, or all three types of fraud. Place your initials next to each of the three options that apply. (see below)

15a. Makers Signature Forged/Unauthorized Signature: Initial this section if your signature on the front of the claimed item was forged or not authorized or approved by you in any manner.

15b. Endorsement Forged: Initial this section if your endorsement on the back of the check/draft item was forged or not authorized or approved by you in any manner.

15c. Altered Check, Withdrawal, Deposit or Deposited Item: Initial this section if the item claimed has been altered in any way from the original entered by you. Write exactly how it was altered from what you originally entered.

16. I also declare that by my initials below I agree to the following: Please read this section carefully. To submit a valid claim to Kinecta, you MUST initial that you have read and agree to these paragraphs.

16a. I did not receive any benefit: Initial this section if you swear under penalty of perjury that you did not receive anything from the proceeds (money) of the fraudulent item and none of the proceeds applied to anything for your benefit.

16b. I have not arranged with the person: Initial this section if you swear under penalty of perjury that you did not arrange with the person(s) who forged the item to receive any benefit in return.

16c. I promise to testify: Initial this section if you swear under penalty of perjury that you promise to testify or certify to the truth of all the signed statements in this declaration. This could possibly include testifying against family members or friends.

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17. I believe the forgery of my name was made by: If you know or suspect someone who is responsible for or knows about the fraudulent activity, enter the name(s) and address(es). If you don’t have this information, enter ‘I do not know.’

18. I am making this statement voluntarily and I swear under penalty of perjury:

Carefully read these statements. If they are true, sign your complete name and add the date you signed in the box at the bottom of the claim.

19. Notarized Signature: The Affidavit of Forgery Claim must be notarized, whether it has been completed in a local Kinecta branch, or is being sent through the mail. This document must be complete and must contain any supporting documentation.

Please sign both the front and back sides of this claim form, as well as the Addendum if applicable.

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20. Additional Member Information (back side of Affidavit): There are 14 questions that must be filled out to the best of your ability. If any questions do not apply to your claim or you do not know the answer to any question, write ‘I do not know.’ Do not leave any question unanswered (blank).

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21. Addendum to Affidavit of Forgery (separate sheet): This form is to be used if you have multiple items that have been forged, altered and/or unauthorized in the same manner (i.e., ten checks each having the same forged maker’s signature on them).

Please fill in all the information requested. Enter each additional claimed item on its own line.

Add the dollar amount of all items and write the total in the spaces provided. Sign and date the Addendum in the spaces at the bottom. This form must also be notarized. If the

addendum is used in your claim, it must be included with the Affidavit of Forgery Claim and all other supporting documentation in the envelope provided by Kinecta.