Information Needed For Criminal Prosecution Determination Form - Merchant Information
Download a blank fillable Information Needed For Criminal Prosecution Determination Form - Merchant Information in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Information Needed For Criminal Prosecution Determination Form - Merchant Information with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Keith County Attorney's Office - 303 West A St - PO Box 29 - Ogallala NE 69153-0029 - (308) 284-2091
The following form must be completely filled out for each Insufficient Funds Check and submitted to the County Attorney's
Office. Each blank must be answered. If the answer is not known, write '"'Unknown" or "None", etc. It is recommended that your
business establish a policy for accepting checks. You should obtain a current address, date of birth and driver’s license
number, by physically, not verbally, receiving identification from the check writer.
MERCHANT INFORMATION
1. Name:
________________________________________________________________________
2. Address:
________________________________________________________________________
3. Telephone:
________________________________
INFORMATION NEEDED FOR CRIMINAL PROSECUTION DETERMINATION
4. Person who took check: __________________________________________________________
5. Their position:
__________________________________________________________
6. Can the person who took the check identify the passer?
7. Did the check passer sign the check in this person's presence?
8. Was identification obtained from the check passer?
If yes, specify:
__________________________________________________________
If you answered "NO" to ALL of the questions 6, 7 and 8, DO NOT fill out the remainder of this form. The County Attorney's
Office is legally unable to prosecute.
9. Did anyone agree to hold the check?
10. Was the check postdated?
11. Was the check used to pay an open/revolving charge account?
12. Has your business received any payments regarding this check?
If you answered "YES" to ANY of the questions 9, 10, 11 or 12 DO NOT fill out the remainder of this form. The County
Attorney's Office is legally unable to prosecute. You may contact a private attorney for other civil remedies available to you.
13. Merchandise Purchased:
__________________________________________________________
14. Has your business had bad checks on this person before?
15. How many times has your business contacted the accused regarding this check?
_______
16. Date(s) and Method of contact: __________________________________________________________
CHECK WRITER INFORMATION:
17. Name:
____________________________________
22. Employer:
____________________________________
18. D.O.B.:
____________________________________
23. Check Amount:
______________
19. Driver’s License #: _______________________________
24. Date of Check: ___________________________________
20. Address:
____________________________________
25.Check#:
_____________
21. Telephone:
____________________________________
26. Bank Charge: ____________________________________
The undersigned states that (s)he has filled out this complaint, that the facts contained herein are true, and that (s)he is willing to testify
in Court to the above facts under oath.
______________________________________________________
Date: ______________________
______________________________________________________
Witness:
_
DO NOT ACCEPT PAYMENT OF CHECK(S) AFTER THEY HAVE BEEN TURNED OVER TO THIS OFFICE FOR
PROSECUTION. DIRECT ALL PAYMENTS TO THE COUNTY ATTORNEY'S OFFICE. PLEASE REMEMBER to bring in your
respective bank slip(s) showing charge for ISF checks, and there is a $10.00 protest fee per check required from the merchant. Upon
successful prosecution, we will collect the protest fee and bank charges from the accused to reimburse you.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal