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
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