May 17, 2023


I [Enter Name] (“Affiant”), of address [Enter Address], who being duly sworn according to law, do make an oath and states as follows:

  1. [Enter Name] of address [Enter Address] is _____ [Enter the relationship between you and the person].
  • [Enter Name] perpetrated fraud as follows:
  • [Describe incidence(s) of fraud]
  • Upon my information and belief, I have duly stated any and all information I have with regards to the fraudulent conduct of [Enter Name].  
  • I understand that an investigation may be done on the facts stated in this Affidavit, and that a civil and/or criminal action against [Enter Name] may be brought for their fraudulent conduct stated herein.
  • I agree to 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.
  • I recognize that any false statement or other misrepresentation made in this Affidavit, may subject me to civil and/or criminal penalties. I further understand that I may not recover for any loss or expense caused by the alleged fraudulent conduct, if I provide false information herein.

I hereby swear under the penalty of perjury that the facts referred to in this affidavit are true, complete and correct.

  Signature of the Affiant: [Your Name]         [Your Signature]
______________________ [Enter Date]  
  For the Notary:Sworn to before me this _________ day of _______________________                    [Signature]
____________________________  Notary PublicState of [Enter State]My Commission Expires: ___________  

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