AFFIDAVIT OF FRAUDULENT TRANSACTIONS Client Name: KeyBank Account Number: Originating KeyCenter or Cost Center: 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 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, defend 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. Affiant will also indemnify, defend and hold KeyBank harmless from any losses, damages, liabilities, claims (including claims of third parties), judgments, suits, penalties, costs or expenses, including, without limitation, attorneys fees, court costs, punitive damages and consequential damages, paid or incurred by KeyBank which arise directly or indirectly out of KeyBank s reliance on this Affidavit, which obligation to indemnify, defend, and hold KeyBank harmless shall continue notwithstanding any applicable statute of limitations or any claim that KeyBank acted with negligence or gross negligence, or engaged in willful misconduct. Account Owner/Business Name/Authorized Signer Name and Title: (For Business Accounts) Relationship to Company: Account Number: Current Address (if different than what it appears on your statement): Daytime Phone Evening Phone {00310489 v1 INTERNAL } Page 1 of 6
Type of Fraud: Forged Maker s Signature Forged/Missing Endorsement Altered Check Altered Payee Counterfeit Check Unauthorized Withdrawal Unauthorized On-Line Banking Transactions Definitions: 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. The Payee of the check alleges that they did not sign or endorse the back of the check. The Maker of the check alleges that the check was written for a specific amount and alleges the amount was altered. The Maker of the check alleges that the check was written to a specific payee and the payee name was altered. A fictitious item drawn off a valid account. The owner(s) of the account allege that a withdrawal transaction was neither authorized nor completed by them. The owner(s) of an account allege that an unauthorized transaction was initiated from/to their account via On-Line Banking or VRU/telephone transfer, into/from an account in which they have no ownership or interest. 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 Item/Transaction Date Item No. (if applicable) Dollar Amount $ Payee 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, and that if this Affidavit is being made with regard to a business account, I am a duly authorized officer of the aforementioned business. Signature of Affiant Print name Business name (if applicable), and signer title if signing on behalf of Business Address, City, State, Zip Subscribed and sworn to me before this Day of Year County of In the State of Notary Public My Commission Expires Place Notary Seal Here {00310489 v1 INTERNAL } Page 2 of 6
Addendum to Affidavit for Additional Items Client Name: KeyBank Account Number: Originating KeyCenter or Cost Center: 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: {00310489 v1 INTERNAL } Page 3 of 6
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 circle 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 circle 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 circle 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 circle one) If yes, when? 6. Has your home or car been burglarized, or has your purse or wallet been stolen recently? Yes / No (Please circle one) If yes, please answer: When Where Were checks stolen? Yes / No (Please circle one) Was your ID stolen? Yes / No (Please circle 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 / No (Please circle one) If you made a report to KeyBank, at what location? {00310489 v1 INTERNAL } Page 4 of 6
8. For this report of fraudulent activity, provide police case number. Police Department City/County Date of Claim Police Report Number 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: {00310489 v1 INTERNAL } Page 5 of 6
KeyBank Use Only KeyCenter or Department Name: Employee Contact Name: Employee Contact Phone #: Employee Contact Signature: Additional Comments: ***Contact the Fraud Hotline @ 1-800-433-0124 to report all fraud claims and answer any procedure questions you may have. {00310489 v1 INTERNAL } Page 6 of 6