Bad Check Crime Report Template - York County District Attorney

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8/29/2016
BAD CHECK CRIME REPORT
YORK COUNTY DISTRICT ATTORNEY
TOM KEARNEY
Victim Services, Inc. Mail Processing
Bad Check Program Contact:
Bad Check Program:
(866) 909-8431
-
Victim Hotline
P.O. Box 1417
(866) 434-1440
-
Check Writer Hotline
(Please refer check writer to the “check writer” hotline)
Lancaster, PA 17608-1417
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 checks
*Post/pre dated or altered checks
*Checks you agreed to hold before depositing
Confirm
Eligibility
*Checks passed outside of York County
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
Address:________________________________________City:________________________State:______Zip Code:____________
Pennsylvania Statute 4105(e-3) provides for the recovery of a bad check service fee provided that notice of this service fee is
conspicuously displayed on your premises. *Please refer to the back of this report for an explanation of service fee.
Is a notice of your service fee conspicuously displayed on your premises?
Yes or
No
If yes, what is the service fee on your notice? Fill in amount here $__________
Driver’s License # / Other ID #:
Check Writer’s Name:_____________________________________________________________
______________________________
Step
Address:______________________________________________________Apt:______________
State:
Date of Birth:
3
________
_____/______/_______
City:_________________________________________ State:________ Zip Code:____________
Check
Other ID: (if applicable)
Writer
______________________________
Home Phone: (_____)______________________ Other Phone: (_____)_____________________
Information
A “Courtesy Notice” must be sent to recover the bad check(s) in question via U.S. Certified Mail including return receipt. If no attempt
has been made, the check is not eligible for prosecution. (See sample notice on back.)
Ck. No.
Date Passed
$ Amount
Name of person accepting check
Can person ID
Step
check writer?
(if no longer employed please list manager)
4
Yes
No
Check
Information
Yes
No
Yes
No
Address where check was accepted (if different than above in 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 (866) 434-1440.
Step
I understand that the check writer has the option to dispute this claim in writing with the Bad Check Program.
If this crime report is not completely filled out it may prevent or delay this case from moving forward for prosecution review.
5
I attest that I have sent courtesy notice to the check writer via U.S. Certified Mail including return receipt 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
Verification
to the best of my knowledge.
Sign & date
X_________________________________________
__________________________________________
__________________
Signature of Person Filing (Required)
Print Name of Person Filing
Date Filed
Additional crime reports are available at:
.
This Program is administered by Victim Services, Inc., a private entity under contract with the District Attorney's Office

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