AFFIDAVIT OF FRAUDULENT TRANSACTIONS - KeyBank

AFFIDAVIT OF FRAUDULENT TRANSACTIONS

Client Name: Originating Branch or Cost Center:

KeyBank Account Number: Prepared By (print):

I, _____________________________________ ("Affiant"), who first being duly sworn according to law, does depose and state: That fraudulent transaction(s) (original or certified copy attached hereto) was not endorsed, signed, authorized, ratified, either expressly or by implication, by Affiant or with the Affiant's knowledge or consent. Affiant did not receive or retain any benefit or value from the transaction(s), either directly or indirectly.

Affiant Acknowledgement Affiant says he/she will testify, declare, depose, certify or acknowledge the truth of any or all of the statements contained herein before a court of competent jurisdiction, officer or person thereof. Affiant recognizes any false statement or other misrepresentation made in this affidavit, may subject him/her to civil and criminal penalties. Affiant understands that he or she may not be refunded for those items/transactions listed on this affidavit until (1) KeyBank has a reasonable time to conduct an investigation and (2) the results of the investigation, in KeyBank's sole opinion, justify a refund. In the event, the Affiant receives provisional credit for the items in question, it is understood that KeyBank may reverse the credit based on the findings of the investigation.

Affiant understands that KeyBank may provide law enforcement authorities with information provided by Affiant which may cause the arrest of a person for the unauthorized transaction(s) in reliance on the representations made by the Affiant. Affiant authorizes KeyBank to initiate legal proceedings against these individual(s). Affiant will give under oath, additional statements as requested to law enforcement officials or KeyBank personnel. Affiant will indemnify and hold harmless KeyBank from any liability arising out of such arrest in the event that the representations made by Affiant should prove to be false or misleading.

Account Owner/Business Name/Authorized Signer Name:

(For Business Accounts) Relationship to Company:

Account Number:

Current Address (if different than what it appears on your statement):

Daytime Phone:

Evening Phone:

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Type of Fraud: Forged Maker's Signature: The Maker of the check alleges that their check(s) have been stolen and the signature on the

front of the check is not theirs. Forged/Missing Endorsement: The Payee of the check alleges that they did not sign or endorse the back of the check. Altered Check: The Maker of the check alleges that the check was written for a specific amount and alleges the amount

was altered. Altered Payee: The Maker of the check alleges that the check was written to a specific payee and the payee name was

altered. Counterfeit Check: A fictitious item drawn off a valid account. Unauthorized Withdrawal: The owner(s) of the account allege that a withdrawal transaction was neither authorized nor

completed by them. Unauthorized ACH Transaction: The owner(s) of the account allege that an ACH transaction was neither authorized nor

completed by them.

For Altered/Forged Endorsement Items: The Altered/Forged Endorsement was first discovered on There is reason to believe the following individual(s), who resides at _________________________________________________________________ may be responsible. If check was altered, provide original Payee and Amount: What was the Payee and/or Amount altered to?:

Provide fraudulent item/transaction information: (Attach Addendum to Affidavit for Additional Items) Item/Transaction Date ________________ Item No. (if applicable) ______________ Dollar Amount $ ______________ Payee Only one item per form ? a separate affidavit is needed for each ACH transaction. Multiple check items may be included on a single affidavit for the same type of fraud.

I hereby swear under the penalty of perjury state that the facts referred to in this affidavit (and any addendum attached hereto) are true, complete and correct.

Signature of Affiant: Print name: Business name, if applicable: Address, City, State, Zip:

Please complete the notary below for checks

Subscribed and sworn to me before this

Day of Year

County of

In the State of

Place Notary Seal

Notary Public

My Commission Expires

Customer Signature: Customer's Signature must be obtained and faxed to (216) 370-4135, or scanned and emailed to Fraud_Hotline@.

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ADDENDUM TO Affidavit FOR Additional Items

Client Name: Originating Branch or Cost Center:

KeyBank Account Number: Prepared By: (print):

The signature on the draft(s)/ check(s)/ document(s) is not my signature, nor did I authorize or ratify, expressly or by implication, the making of such signature. Further, I have received no benefit or value from said draft(s)/ check(s)/ document(s) or the payment thereof, either directly or indirectly.

Item # (If applicable) Date

Amount

Payable to

Drawn on

The forgoing addendum was prepared contemporaneously with my AFFIDAVIT OF FRAUDULENT TRANSACTIONS and is incorporated therein and is attested to and sworn by me as a part of my execution of the affidavit. Client Signature: ___________________________________ Date: _____________________________ Client Home Phone: _________________________ Work Phone: _____________________________

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Fraud Affidavit Questionnaire

Answer the following questions (if applicable):

1. When did you discover the fraud? (Date) Please explain any delays in discovering or reporting the fraud:

2. Do you have any idea who might have been involved in the fraud (i.e. friend, relative, roommate, employee)? Yes No (Please check one) If yes, what is the name of the individual? What is the address of the individual?

3. Have you ever allowed someone to sign your checks? Yes No (Please check one) If yes, what is the name of the individual? Did this person sign your name or their own name on the check? My name Their name

(Please check one)

4. Where were you storing your checkbook / check stock at the time of the theft/unauthorized use?

5. Have you ordered checks recently that have not been delivered to you? Yes No (Please check one) If yes, when?

6. Has your home or car been burglarized, or has your purse or wallet been stolen recently? Yes No (Please check one) If yes, please answer: When Where Were checks stolen? Yes No (Please check one) Was your ID stolen? Yes No (Please check one)

If you answered Yes to the above questions and a police report was filed, please provide the following information. Police Department City/County Date of Claim Police Report Number

7. Have you reported a previous fraud claim to KeyBank or any other institution? Yes If you made a report to KeyBank, at what location?

8. For this report of fraudulent activity, provide police case number.

Police Department City/County Date of Claim Police Report Number

No (Please check one)

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Corporate or Business Accounts (if applicable):

Have you hired or fired any employees who would have had the opportunity to commit this forgery? If yes, please provide name(s) and any information you may have:

Did anyone have authorized access to your checks recently? If yes, please provide name(s) and any information you may have:

Additional Comments:

Branch or Department Name: Employee Contact Name: Employee Contact Phone #: Employee Contact Signature:

Additional Comments:

KeyBank Use Only

***Please fax a completed copy of this affidavit to (216) 370-4135.

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