Complete this form and attach certified letter receipt or returned letter and any
receipts for merchandise to back of form.
*PLEASE NOTE* ** THIS OFFICE WILL NOT ACCEPT ANY CHECK WITHOUT THE INFORMATION MARKED WITH **
MAKER OF CHECK: Mr./Mrs./Ms. ______________________________________________________________________________________
**DRIVER'S LICENSE: STATE: _____________________ #_______________________________
**DOB/AGE: ___________________________________ SS#________________________________
**HOME ADDRESS:_______________________________________________________ PHONE #( )_________________
STREET CITY ZIP
BUSINESS ADDRESS:______________________________________________________ PHONE #( )_________________
**DESCRIPTION OF MAKER: SEX _______ RACE ________ HEIGHT _______ WEIGHT ________ HAIR _______
EYES ________ DISTINGUISHING MARKS______________________________________________________________________________
*DATE OF CHECK: _______________ AMOUNT: $______________ BANK: ___________________________________________________
REASON CHECK RETURNED: (CHECK ONE) _______ NSF _______ ACCOUNT CLOSED
________ OTHER (PLEASE SPECIFY) _______________________________________________________________
CHECK GIVEN FOR: ____ CASH ____ SALARY ____ LOAN ____ FUTURE RENT ____ PAST RENT
_____ MERCHANDISE ____ GROCERIES ____ OTHER (PLEASE SPECIFY PRICE, QUANTITY, AND
DESCRIPTION OF EACH LISTED ABOVE: ______________________________________________________________________________
__________________________________________________________________________________________________________________
**PERSON WHO TOOK CHECK FROM MAKER: ____________________________________________________________________
ADDRESS: ______________________________________________________________ PHONE # ( ) _________________
STREET CITY ZIP
CAN HE IDENTIFY MAKER IN COURT? ____ IF SO, HOW? ____________
DID HE TAKE CHECK THINKING IT TO BE GOOD? YES _____ NO _____
WAS THIS A POST-DATED OR HOLD CHECK? YES _____ NO _____
WAS CHECK RECEIVED IN THE MAIL? YES _____ NO _____
WAS CHECK GIVEN AS PAYMENT TOWARD THE BALANCE ON A PRE-EXISTING ACCOUNT? YES _____ NO _____
WAS CHECK GIVEN AS PARTIAL PAYMENT FOR PURCHASE? YES _____ NO _____
HAS THE MAKER MADE ANY PAYMENT TOWARDS THE CHECK? YES _____ NO ______
MONEY COLLECTED SHOULD BE SENT TO: __________________________________________________________________
ADDRESS: _____________________________________________________________ PHONE # ( ) _________________________
STREET CITY ZIP
YOUR NAME:______________________________________________________ POSITION/TITLE: _________________________________
I, _____________________________________________________________________ HEREBY STATE THAT THE
(YOUR SIGNATURE)
ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
**** PLEASE DO NOT ACCEPT ANY PAYMENTS ONCE CHECKS HAVE BEEN TURNED OVER
TO THE DISTRICT ATTORNEY'S HOT CHECK DEPARTMENT FOR COLLECTION AND PROSECUTION. ****