Bad Check Crime Report Form - Santa Clara County District Attorney'S Office
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1
2BAD CHECK CRIME REPORT
5/09/2011
SANTA CLARA COUNTY DISTRICT ATTORNEY’S OFFICE
Bad Check Program Contact:
Bad Check Program Address:
(877) 520-6137 -
P.O. Box 26370
Merchant Hotline
(800) 931-9720 -
San Jose, CA 95159-6370
Check Writer Hotline
(Please refer check writer to the “check writer” hotline)
For more information:
Step
The following types of checks are ineligible for the program:
*Two-party checks
*Partially re-paid checks
*Fraudulent or stamped lost/stolen/forged
1
*Payroll, credit card or equipment rental checks *Post/pre dated or altered checks
*Checks you agreed to hold before depositing
Confirm
*Checks passed outside of your county
*Checks which are repayment of loan or civil contract agreement
Eligibility
Victim/Merchant Name:__________________________________________________________________________________
Step
Contact Name: ____________________________________________ Title: ________________________________________
2
Victim Contact Information:
Email: ________________________________________________________
Victim
(Required)
Information
__________
Phone:(______)___________________Fax:(______)________
•
Email and/or fax are required for acknowledgement receipt of check and/or Program communication
Code:____________
Address:________________________________________City:______________________State:______Zip
If assessed a bank charge(s) for the attached bad check(s) please state the amount of the bank charge per check
$_________________
(Per California Penal Code 1001.65 (c) you are eligible to be reimbursed up to $15 per check for assessed bank charges.)
Driver’s License # / Other ID #:
Check Writer’s Name:____________________________________________________
Step
____________________________
3
Address:______________________________________________ Apt:______________
State:
Date of Birth:
_______
_____/______/______
Check
City:__________________________________ State:________ Zip Code:___________
Writer
Other ID: (if applicable)
Information
Home Phone:(_____)__________________Other Phone:(_____)_________________
___________________________
Written notice must be sent to recover the bad check(s) in question. If no attempt has been made, the check is not eligible for prosecution.
( See courtesy notice on back.)
Ck. No.
Date Passed $ Amount Name of person accepting check
What was the
Can the check
Step
Check for?
writer be identified
?
(if no longer employed please list manager)
4
Yes
No
Check
Yes
No
Information
Yes
No
Address where check was accepted (if different than Step 2):______________________________________________________ (Required)
City:________________________________________ State:_______ Zip Code:____________________
•
I will not accept direct payment from the check writer after filing this report with the Program. Please refer check writer to (800) 931-9720.
Step
•
I understand that the check writer has the option to dispute this claim in writing with the Bad Check Program.
•
5
If this crime report is not completely filled out it will prevent or delay this case from moving forward for prosecution review.
•
I attest that I have sent notice to the check writer and after 10 days it remains unpaid.
Victim
•
I have reviewed the filing instructions, I hereby affirm and attest under penalty of perjury, that all information provided on this crime report is true to the best
Verification
of my knowledge.
Sign & date
X_________________________________________ _____________________________________ _______________________
Signature of Person Filing (Required)
Print Name of Person Filing
Date Filed
Additional crime reports are available at:
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