Complaint Form - Harris County District Attorney

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HARRIS COUNTY DISTRICT ATTORNEY
CHECK FRAUD COMPLAINT FORM
The undersigned Affiant, who after being duly sworn by me makes the following statements under oath:
I have good reason to believe and do believe that the below listed person, herein after called the accused, did commit the offense of theft
by passing a worthless check. My belief is based upon the following facts as shown by the appropriately completed information as set out
below, to-wit:
CHECK WRITER’S COMPANY NAME
NAME OF PERSON WRITING THE CHECK (S)
NAME OF CHECK RECEIVER
DOB
ADDRESS/CONTACT NUMBER IF KNOWN
NAME OF MERCHANT
ADDRESS OF TRANSACTION
COUNTY/CITY/STATE
ZIP CODE PHONE NUMBER
SPECIFY (IN DETAIL) PROPERTY OR SERVICE PURCHASED: __________________________________________________________________
HOW CAN YOU IDENTIFY THE ABOVE NAMED DEFENDANT? Texas Drivers License 
Other ____________________________
(PLEASE SPECIFY)
FROM THE SIGNOR IN THE MAIL THIRD PERSON , ___________________________
HOW WAS CHECK RECEIVED?
 
 
WAS THIS A HOLD CHECK?
YES
NO
WAS THIS A POST-DATED CHECK? YES
NO
HAVE YOU HAD CONTACT WITH CHECK WRITER?________________________________________________________________________
IF YOU HAVE RECEIVED RESTITUTION ON THIS CHECK, HOW MUCH AND WHEN? _________________________________________
MERCHANT CONTACT INFORMATION FOR RESTITUTION:
IF SAME AS ABOVE, WRITE “SAME”
(PLEASE UPDATE OUR OFFICE IF THIS INFORMATION CHANGES)
MERCHANT MAILING ADDRESS
COUNTY/CITY/ STATE
ZIP CODE
PHONE NUMBER (S)
I UNDERSTAND THAT A WARRANT CAN BE ISSUED ONLY ON CHECKS WHERE THE RECEIVER OF THE CHECK
REQUIRED PROPER IDENTIFICATION OR WHERE THE ACCUSED CAN OTHERWISE BE IDENTIFIED. I hereby swear or
affirm that the above information is true and correct to the best of my knowledge; that the above check(s) was given in Harris County,
Texas; that said check(s) was not postdated or a hold check(s); that said check(s) was believed to be good when it was accepted; that said
check(s) was presented to the bank for payment within 30 days after receipt; that proper identification was required on each check listed
above (*except as set out below); that a certified notice, return receipt requested, has been sent for all checks listed above and more than
10 days have passed and restitution has not been paid. I swear or affirm that I personally received said check(s) from the accused or that I
have spoken to the above listed check receiver(s), who is credible, who works with me, and who stated that he/she received a check from
the accused in the manner as set forth above. I also understand that if the accused should contact me or my company to pay restitution, I
S
should immediately refer them to the DA’s Office for payment.
T
(If any of the above statements do not apply cross them out, initial the change, and explain the change on the reverse side of this affidavit.)
A
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________________________________
_____________
_______________________________________________________________
Affiant’s DOB
Typed/Printed Name of the Affiant
Affiant Signature and Title
C
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SUBSCRIBED AND SWORN BEFORE ME BY THE SAID ___________________________ ON THIS THE ____ DAY OF __________________, 20____.
E
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______________________________________________
Signature of Notary Public in and for the State of Texas
My Commission Expires ___________________.
H
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Please provide any additional information on back of this page if necessary.
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K:1officedocuments/complaintform.doc

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