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Check Handling Information APPENDIX I and Procedures 10/18 Page 18

INSTRUCTIONS FOR PREPARATION OF AFFIDAVIT OF CHECK FRAUD BY PAYEE FORGED ENDORSEMENT

Endorsement Forged The payee should check the box if check was not signed or authorized by the payee

Check No.

Enter the complete 8-digit check (warrant) number

Date

Enter the date on the check

Amount

Enter the entire amount of the check, including cents

Made Payable to

Enter the payee name

Payee Name and Title/Signature

Enter the payee printed name then signature

Date

Enter the date the affidavit is signed

Address

Enter the current address (as shown in VaCMS)

City, State and Zip Code

Phone Number

Enter payee telephone number

Notary Blanks must be completed with Notary information, signed by Notary, and imprinted with the Notary seal

TANF Transmittal 65