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Bad Check Complaint Form

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  2. Bad Check Complaint Form
    If the bad check writer has not responded to your notice after ten (10) days, please fill out this form, upload a copy of the notice letter and bad check, and submit to our office.
    1. One complaint for each check must be filled out.
    2. Keep the original check and any other items for 90 days.
    3. Please do not accept any money without contacting our office; doing so may prevent full recovery or prosecution.
  11. Date check was written
  13. Amount the bank charged your business.
  14. check amount + bad check fee
  16. person who signed/wrote the check
  22. How Was This Check Received?*
  23. Did You Record the Driver's License Number?*
  26. Is it your normal practice to compare ID containing a photo in the presence of the check writer?*
  28. Do you personally know the check writer?*
  29. Could you identify them in a photo line-up or in court?*
  31. Please upload a copy of the notice letter mailed to the bad check writer.
  32. Please upload a copy of the bad check.
  34. Electronic Signature Agreement*
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  37. Please upload any additional information you might find helpful.
    38. Leave This Blank:

  40. This field is not part of the form submission.