DELAWARE HEALTH & SOCIAL SERVICES
DIVISION OF CHILD SUPPORT ENFORCEMENT

AFFIDAVIT OF FORGERY FOR CHECK LOST OR STOLEN

PAYEE INFORMATION

TO BE COMPLETED BY WORKER
Name:
  

Case Number:

Address:
                  

Check Number:


  

Check Date:


 

Check Amount:

Daytime Phone #:
 

Worker Code:


I, 						(Print) being duly sworn, do hereby depose and say that I 
have not endorsed said check.  If said check is endorsed, the signature thereon is not my signature and that the said 
endorsement appearing thereon purporting to be mine was affixed to said check by person or persons unknown to 
me and without any authority from me to do so.  I further depose and say that I have not received the benefits or 
proceeds of the said check, and if said check is found I hereby agree to return it immediately to the Division of 
Child Support Enforcement.  It has been explained to me and I know that I can be prosecuted for false statement.




						(Attest)	 						
Signature of Payee							Date




						(Optional)						
Signature of any witness (non-notary) to Payee Signature 			Date




						(Notary Signature)

Sworn and subscribed to, before me, a Notary Public, this 		 day of 			 , 20	       .

My commission expires on 				.

***PLEASE READ BEFORE SUBMITTING FORM TO DCSE***
*	Affidavit of Forgery must be made in triplicate.  Signatures on all three copies must be original.
*	A separate Affidavit of Forgery must be made for each check alleged lost or stolen. Do not list more than one 
check on this document.

*	Do not attempt to cash any check for which an Affidavit of Forgery claim has been completed.  DCSE will 
immediately place a stop payment on the said check once the forgery claim is received.

*	Once the Affidavit of Forgery is submitted to the bank, the bank may take an average of 90 days to research 
before it is determined whether a replacement check can be issued.

P.O. Box 12811 * Wilmington * Delaware * 19850