I may be the person you are looking for. Please compare this to your records and see if you are holding any money for me!
Name: ___________________________________________________________
Address: ___________________________________________________________
City, ST, ZIP: ___________________________________________________________
Telephone (____) _____-_____________
Social Security Number ________________________
Name of Credit Union __________________________________________________________
Signature __________________________________________________________
State of _________________}
County of _______________}
I, ________________________, do hereby solemnly swear (or affirm) that I had shares in a credit union that was liquidated by the National Credit Union Administration as indicated above.
I understand that presenting a false or fraudulent
claim, in whole or in part, to the National Credit Union Administration
for share insurance may subject me to criminal and/or civil penalties
as provided for in 18 U.S.C. §287 and 31 U.S.C. §3729,
respectively.
____________________________
AFFIANT (Signature)
Signed and sworn to (affirmed) before me
_________________________,
this_________ day of _____________, 20___, by
(Notary Public)
________________________________.
(Affiant Name)
__________________________________My commission expires ________________________
NOTARY PUBLIC