Dishonored Check And Notice And Demand For Payment printable pdf download

Dishonored Check And Notice And Demand For Payment

DISHONORED CHECK

Check was accepted and/or approved by: Name: _________________________________________________

Home Address: _____________________________________________ Date of Birth: ___________________

Home Phone: _________________________ Employer: ___________________________________________

Work Address: _______________________________________________ Work Phone: __________________

Date check was accepted: _______________________ List items/service received:______________________

Date of check: ___________________ Amount of check $______________ Cash returned: $____________

Check was written by: Name: _________________________________________________________________

Address: __________________________________________________________________________________

Check was received in person. YES / NO

Check was written in my presence. YES / NO

Driver’s License #: ________________________________________ State: ____________________________

Description of defendant (REQUIRED if no Driver’s License #):

M / F

Race: ____________________

Date of Birth: ________________ Height:_________ Weight: _________ Hair: ________ Eyes: _________

Miscellaneous Information: ___________________________________________________________________

Vehicle Make: ____________________ Vehicle Color: _________________ License Plate: ______________

I CAN IDENTIFY ON SIGHT THE WRITER OF THE CHECK, OR I HAVE FOLLOWED THE

PROCEDURES AS OUTLINED IN THE DISHONORED CHECK PROSECUTION POLICY, AND AM

WILLING TO TESTIFY IN COURT IF NECESSARY.

______________________________________________________

(Signature of person accepting/approving check)

I HEREBY ATTEST THAT THE ABOVE REFERENCED CHECK HAS NOT BEEN PAID IN FULL

WITHIN THE FIVE BUSINESS DAYS AFTER MAILING OF THE NOTICE AND DEMAND FOR

PAYMENT OF DISHONORED CHECK.

______________________________________________________

(Manager or owner of business)

(Date)

Revised 6/05

Dishonored Check And Notice And Demand For Payment