Check Fraud Questionnaire Template printable pdf download

CHECK FRAUD QUESTIONNAIRE

INSTRUCTIONS:

This questionnaire MUST be filled in completely by the person who

ACCEPTED the check and/or the person who APPROVED acceptance of the check. There are

certain questions as to identification of the presenter of the check which only the ACCEPTOR or

APPROVER can answer. If the information is incomplete or lacking, the District Attorney may

not decide to bring criminal charges.

Check # ________ Amount $____________ Date ______________ Case Number_________

Victim ______________________ Address ________________________ Phone: __________

E Mail _________________________ Cell: ____________

1. Name, address, and telephone numbers of person who received the check, and of the

person who approved receipt of the check.

A) Person who RECEIVED check _________________ Address _____________________

DOB: ____________ Phone: _____________________

B) Person who APPROVED check ________________ Address ____________________

DOB: ____________ Phone _____________________

2. Was the check delivered in person _____ or by mail _____

3. Where was check received ___________________________________________________

4. Was check returned insufficient funds_____ or was the check drawn on closed account ____

5. Date check deposited _______________ Returned unpaid or refused by bank ___________

6. Total Amount of Purchase $__________ Value of service/msde delivered $_____________

How much cash was delivered ________Describe service/msde delivered or attach a copy

of receipt _________________________________________________________________

7. Was presenter of check known by either the person who received the check or the person

who approved acceptance of the check? Yes ____ No ____ Explain: _____________________

Was the check filled out and signed by presenter in the presence of the person who

accepted/approved acceptance of the check? Yes _____ No ____.

Was it a single party check? Yes ____ No ____

10. Was the check dated the same day it was delivered to the victim? Yes ____ No ____

11. Was the check dated for a date in the future? Yes ____ No ____

12. Were you asked to hold check for a period of time until money was put into the account, or

until the presenter got some money or funds from another source? Yes ____ No ____

13. What efforts have you made to collect on the check?

(A) Phone call ____ How many ____ When ________ What telephone number_________

(B) Personal contact ________ How many _________

Check Fraud Questionnaire Template