Worthless Check Referral Sheet/worthless Check Affidavit/worthless Check Witness Form printable pdf download

Please fill out this referral sheet below, affidavit, and witness list when referring worthless checks to the

State Attorney's Office.

Fill in all required areas.

Do not write in the gray boxes.

An affidavit is a legal

document that must be filled out accurately.

Make sure to attach a LEGAL COPY of the check (from your bank) to

the affidavit.

Also include any contract, lease, or paperwork that was collected from the check writer about

this check, if applicable. IF YOU MAKE ANY PAYMENT AGREEMENTS OR TAKE ANY MONEY FROM THE CHECK WRITER AFTER YOU

HAVE REFERRED THE CASE TO OUR OFFICE, WE WILL BE UNABLE TO ACCEPT THE CASE IN OUR PROGRAM.

ADDITIONALLY, IF

CHECK WRITER PAYS YOU DIRECTLY, IT IS IMPERATIVE THAT YOU CONTACT OUR OFFICE IMMEDIATELY.

WORTHLESS CHECK REFERRAL SHEET

OFFICIAL USE ONLY

Check Writer's Name _______________

DO NOT WRITE IN THESE BOXES

Or Check Business Name

_________________

(if applicable)

Assigned SPN ____________________

Victim's Name ______________________

Assigned SPN ____________________

Name and address for restitution correspondence:

__________________________________________________________________

NA ME

STREET ADDRESS

CITY, STATE, ZIP

Contact phone number(s) __________________________

HOME PHONE, INCLUDING AREA CODE

__________________________

WORK PHONE, INCLUDING AREA CODE

__________________________

CELL PHONE, INCLUDING AREA CODE

Check Writer identification

(SELECT ONLY ONE)

_____

Prior knowledge of or acquaintance with check writer

_____

Personal recollection of the check writer at the time the check was received

_____

Driver's License, ID card, or identifiers recorded on check by taker at time of receipt

_____

Personal data recorded on contract, lease, or agreement (include this documentation)

_____

I cannot ID check writer.

OFFICIAL USE ONLY - DO NOT WRITE BELOW THIS LINE

PROSECUTABLE _____ DIVERSION ONLY _____ FELONY _____

MISDEMEANOR _____

GROUP # _____ VERIFYING INFO __________________________________________

REMARKS: _______________________________________________________________

COMPLETE THIS FORM, AFFIDAVIT (ALONG WITH LEGAL COPY OF CHECK ATTACHED),

WITNESS LIST, AND SUPPORTING DOCUMENTS (if applicable), AND MAIL TO:

OFFICE OF BERNIE McCABE, STATE ATTORNEY

BAD CHECK DIVERSION PROGRAM

PO BOX 5028

CLEARWATER, FL 33758

TELEPHONE NUMBERS:

PINELLAS (727)464-6011

NEW PORT RICHEY (727)847-8158

DADE CITY (352)521-4333

Worthless Check Referral Sheet/worthless Check Affidavit/worthless Check Witness Form

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