Check Fraud Questionnaire Template (Page 2 of 2) in pdf

(D) Filed lawsuit in court _____ Case number __________________

14. Has any restitution been received? Yes ____ No ____ If yes, how much? $ _________

15. Was the check given for payment in part or full on a charge account? Yes ____ No ____

16. Was the check given for an old (90 days or more) unpaid debt? Yes ____ No ____

17. Was check payment on another insufficient funds check in whole or in part? Yes___ No ___

18. Were identification documents presented to verify identity? Yes ____ No ____

If yes, describe type: Drivers License __________ Military ID ________ Other __________

Document Number: ______________ Issued by: _________________________________

19. Did you note the document number anywhere? Yes ___ No ___ Where _______________

20. Did you compare the photo on the ID with the person presenting the check? Yes ___ No __

If yes, did the person appear to match the photo? Yes ____ No ____

21. Give a full description of the person delivering the check:

Name _________________________ Alias _____________________ DOB ___________

Address _______________________ Phone ____________________ Race ___________

Sex ___ Age ____ Height ____ Weight ____ Hair ____ Eyes ____ Build _______________

Complexion __________ Glasses ______ Dress ____________

Where employed ____________________ Occupation ____________________________

Other ID exhibited ___________________

22. Auto description: Make _______________ Model _____________ Year _____ Color ____

License Number ______________ State ____________ Style ________ Condition_______

23. Name of person completing this form: ___________________________ DOB: __________

___________________________ DOB: __________

* If not completed by the person ACCEPTING/APPROVING the check, (See Instructions)

please state reason: ___________________________________________________________

____________________________________________________________________________

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Check Fraud Questionnaire Template Page 2