Affidavit of Forgery, Alteration, Counterfeit or Unauthorized Remotely Created Check (Document 20-2)
Summary
Document 20-2, filed 01/25/22, in Case 1:21-cr-00523-TNM, is a Citibank form titled Affidavit of Forgery, Alteration, Counterfeit or Unauthorized Remotely Created Check. The form has a section to describe the disputed item and a claim description with options for a forged or unauthorized drawer's signature, a forged endorsement, an altered amount or payee name, a counterfeit check and an unauthorized remotely created check. Its claimant's statements say the claimant received no benefit from the proceeds and was not negligent, and that false statements to Citibank are a crime. It ends with a signature line for the claimant and a notary acknowledgment block.
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Cite this document
“Affidavit of Forgery, Alteration, Counterfeit or Unauthorized Remotely Created Check (Document 20-2).”
Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/court-filing-united-states-v-elias-eldabbagh-dkt-20-2-d-d-c-34bb3182c1/
, SHA-256 0165b54ed58686e90a306d560032bb62067e5d339caaef71c0ae7089e77cd9bd.Full text
Case 1:21-cr-00523-TNM Document 20-2 Filed 01/25/22 Page 1 of 1
AFFIDAVIT OF FORGERY, ALTERATION, COUNTERFEIT OR
UNAUTHORIZED REMOTELY CREATED CHECK PLEASE PRINT LEGIBLY
Do not use for counterfeit official checks or money orders.
Claimant Name (Business or Individual) Account Number
Street Address Home Telephone Number
( )
City, State, Zip, Country Business Telephone Number
( )
DESCRIBE THE DISPUTED ITEM (Select type of item/transaction and enter details)
Date Check/Serial # Amount For additional checks, complete the Addendum to Affidavit
$ of Forgery. Is Addendum attached? Yes No
Remotely Forgery
Drawer (i.e., maker) Payable to the Order of
Created Check Alteration
Check Counterfeit This Claim involves a Substitute Check* Yes No
*A substitute check is a paper reproduction of the original check that contains an image of the front and back of the original check and bears a legend, “is a
legal copy of your check.”
Forgery Date Purchased: Check/Serial # Purchaser Name:
Official Check Alteration
Money Order Lost / Never Received Amount: Payee Name:
Must select “Endorsement Forged/Unauthorized” below $
Date: Amount : For additional withdrawals, complete the Addendum to
In-Branch Withdrawal $ Affidavit of Forgery. Is Addendum attached?
Yes No
CLAIM DESCRIPTION
The items described above were improperly paid because of a(n) (Check all that apply):
Drawer’s Signature Forged/Unauthorized
The drawer’s signature of ______________________________________________(drawer’s name) on the check or withdrawal order is a forgery or is unauthorized. I did not sign and I
did not authorize the signature.
Endorsement Forged / Unauthorized
The Endorsement of __________________________________________________(payee’s name) on the above check is a forgery. I did not write or authorize the endorsement.
Check (or Remotely Created Check) Amount/Payee Name Altered
The amount of the above check was raised from the original amount of $___________________(amount) to $__________________(amount). I did not raise the amount of the check
and I did not authorize that it be raised. I received no part of the amount of item in excess of the original amount, nor was any part of the excess amount applied to any use or purpose
on my behalf.
An unknown person altered the payee’s name on the check to make it payable to the order of:_________________________________. I did not alter the payee’s name and I did
not authorize any alteration.
Counterfeit Check
This check is a counterfeit and was not authorized by me. I received no benefit from the payment of this check.
Unauthorized Remotely Created Check
The remotely created check was not authorized by me and I received no benefit from the issuance of this transaction. The person who issued the remotely created check is not
authorized to use the account.
CLAIMANT’S STATEMENTS
1. I did not receive any benefit or value from proceeds of the check/withdrawal order, and proceeds were not used for any purpose on my behalf.
2. I have not arranged with the person(s) who forged/altered the check/withdrawal order to be reimbursed for proceeds of the check/withdrawal order. I do not carry any insurance
applicable to the loss resulting from the forgery/alteration. I suspect: _______________________________________________________________________(Suspect Name) of,
___________________________________________________________________(Suspect Address), of having forged or altered the item(s) described in this Affidavit, as I have
stated above. I believe this person did this under the following circumstance: __________________________________________________________________________________.
3. I, the Claimant, was not negligent in contributing to the forgery/alteration and discovered the forgery/ alteration on ________________________________(date), under the following
circumstances: __________________________________________________________________________________________________________________________________.
4. If applicable, I am the payee of the check(s). The check(s) were delivered to me under the following circumstances:
_____________________________________________________________________________________________________________________.
5. I understand that Citibank is a federally insured bank and that my making any false statements to Citibank in connection with my claims, or to induce Citibank to rely upon those
statements, is a crime. I also understand that Citibank or other persons or entities, such as law enforcement may require my assistance in connection with any criminal or civil prosecution
of the wrongdoer(s). Should that arise, I agree to cooperate fully, including the giving of testimony and appearing at a trial. Should I refuse to cooperate, Citibank may revoke any
settlement it offered or paid to me, including charging the amount of any settlement to any account I hold at Citibank.
6. I declare under penalty of perjury under the laws of the State of ________________________________(State) that the foregoing is true and correct.
Claimant’s Signature Date If Claimant is a Business, Print Name/Title of Authorized Signer
X
State of ________________________________ Notary Seal
County of _______________________________
On _____________________________ before me, ___________________________________________(officer’s name and title),
Personally appeared __________________________________________________, who proved to me on the basis of satisfactory evidence to
be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or entity upon behalf of which the
person(s) acted, executed this instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
________________________________________________
2
Notary Public Signature
© 2013 Citibank
Citibank, N.A. Member FDIC. 10-2013 – CA VERSION
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