PLEASE PRINT OR TYPE                                 DATE FILED: __________________

MAKER OF CHECK: ___________________________________________________

HOME ADDRESS: _____________________________________________________

BUSINESS ADDRESS: __________________________________________________

DRIVER’S LICENSE NO.: __________________ ST.___________DOB: __________

RACE: _____________________ SEX: ____________________ AGE: ____________

TELEPHONE NO. HM.(    )__________________ WK. NO. (      )_________________

HAVE YOU CONTACTED SIGNER? ____________ HOW? ____________________

CHECK WAS GIVEN FOR:  CASH, SALARY, MERCHANDISE, RENT, OTHER

 

HAS FULL OR PARTIAL PAYMENT BEEN MADE?  YES_________ NO________

CHECK WAS RECEIVED OR ACCEPTED IN __________________ COUNTY.

PERSON WHO TOOK CHECK FROM MAKER_______________________________

CAN HE/SHE IDENTIFY MAKER IN COURT     YES__________ NO ____________

COMPLAINANT’S NAME (MERCHANT)____________________________________

ADDRESS: _____________________________________________________________

TELEPHONE NO.: (         )_________________

CHECK NUMBER              DATE OF CHECK              AMOUNT OF CHECK
_______________               ________________              ___________________
_______________               ________________              ___________________
_______________               ________________              ___________________

ALL PAYMENTS MUST BE SENT TO THE DISTRICT ATTORNEY’S OFFICE!

 

                                           ______________________________
                                                     COMPLAINANT