ALL CAPS NAME

123 Example Street

City, California 92626

AFFIDAVIT OF NON-SIGNATURE BY ALL CAPS NAME

STATE OF CALIFORNIA
COUNTY OF ORANGE

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I, Upper and Lower Case Name, your Affiant, being competent to bring forth this AFFIDAVIT, and this is
my good faith effort to do so, do declare the following facts to be true, correct and complete, not misleading and
under the penalty of perjury, under the laws of the United States of America (pursuant to Title 28 USC 1746(1)),
and do so state that:
Your Affiant, Upper and Lower Case Name, has personal knowledge of the facts declared herein; and
Your Affiant is describing the attached instrument (Exhibit A) copy which was to setoff and discharge debt
for PERSON GETTING DISCHARGE, CHASE LOAN ACCOUNT # XXXXXXXXX, CHASE, 3415 VISION DR,
Columbus, Ohio 43219; and
3.
Your Affiant has read the Black's Law Dictionary 5th Edition definition of the word account/closed account
in which is states: Closed Account: An account which no further additions or subtractions can be made on
either side, but which remains still open for adjustment and set-off, which distinguishes it from an account
stated.
4.
Your Affiant also has not been made aware by any financial institution that they have received any
benefit or harm from this instrument as listed in #2; and
5.
Your Affiant affirms that this instrument was never to be deposited; and
6.
Your Affiant attests that above the signature line of said instrument in #2 was written, All Rights
Reserved which is a reservation of all rights with full protections under the law and with no waiver of any right;
and
7.
Your Affiant has not received any personal direct or indirect benefit, nor deduction or addition of credit of
any kind; and
8.
Your Affiant has not seen any personal direct or indirect benefit, nor deduction or addition of credit of any
kind to said account as listed in line #2.
9.
Your Affiant, after reviewing the aforementioned instrument, has made a determination of non-signature
regarding said instrument; A signature as lawfully defined in Black's Law Dictionary 5th Edition: Signature:
"The act of putting one's name at the end of an instrument to attest its validity;; and therefore;
10.
Your Affiant, hereby and fore ever declares non-signature from said instrument listed in the above line #2
making it VOID AB INITIO; and
1.
2.

Further Affiant saith naught.

___________________________ ______________
Upper and Lower Case Name
Date

Notary Acknowledgement
STATE OF CALIFORNIA
COUNTY OF ORANGE

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Subscribed and sworn to (or affirmed) before me on this ____ day of ______________, 2013 by Upper and Lower
Case Name; who proved to me on the basis of satisfactory evidence to be the person who appeared before me.

____________________________
Notary Public Signature

(Seal)