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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.

4. Business Name and Address*
6. Business Phone Number*
7. Alt. Number
9. Check Number*
10. Check Amount*
11. Date Issued*
    Date check was written
13. Bad Check Fee*
    Amount the bank charged your business.
14. Total Owed*
    check amount + bad check fee
16. Check Writer's Name*
    person who signed/wrote the check
17. Name of person who accepted check*
19. List Address Where Check was Passed if Different from Business Address
20. What Day Did You Send the 5-day Notice?*
22. How Was This Check Received?*

    1. In Person
    2. By Mail
    3. By ATM
    4. Other
23. Did You Record the Driver's License Number?*

    1. Yes
    2. No
24. If yes, what is the number?
26. Is it your normal practice to compare ID containing a photo in the presence of the check writer?*

    1. Yes
    2. No
28. Do you personally know the check writer?*

    1. Yes
    2. No
29. Could you identify them in a photo line-up or in court?*

    1. Yes
    2. No
31. Copy of Notice Letter*
    Please upload a copy of the notice letter mailed to the bad check writer.
32. Copy of Bad Check*
    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.

    1. I agree.
36. Electronic Signature
37. Additional Documents
    Please upload any additional information you might find helpful.
Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit Submit and Print

* indicates a required field