BAD CHECK COMPLAINT FORM

ONE FORM FOR EACH CHECK SUBMITTED

NOTE: After the complaint has been filed with the District Attorney's Office if the complainant/merchant wishes to withdraw the complaint for good cause. The complainant/merchant shall pay a statutory fee of $30.00 to the District Attorney's Office for processing such complaint.

COUNTY WHERE CHECK ACCEPTED:

VICTIM DATA:

Name of business/person suffering loss on check specific legal name of company)

Business/Person Address:

Business/Person Phone: Work Home

Person Who Accepted Check:

Acceptor's Occupation: (Clerk, manager, cashier, etc.)

DEFENDANT DATA:

Defendant's Name: Address:

Phone: Home Work

Race Sex

Date of Birth SSN or Driver's License No.

Defendant's Place of Employment:

Amount of Check: Date Check Accepted:

Can Acceptor Identify Suspect? Yes No - How?

Was the check Written In Acceptor's Presence?

Property Obtained?

Did Acceptor Agree To Hold Check?

Was Check Post-Dated?

CERTIFICATION

I hereby certify that the above information is true and that my only interest in this matter is the prosecution of the above named individual and I will cooperate with the prosecution of this crime. I will not request that the complaint on this case be dismissed. Nor will I accept payment from the above named individual without prior consent and approval of the District Attorney's Office.

SIGNATURE DATE

PRINTED NAME

STATUTORY NOTICE LETTER TO WRITER OF BAD CHECK

TO:

Dear

This statutory notice is provided pursuant to section 97-19-57 Mississippi code of 1972. You are hereby notified that a check, draft, or order numbered , apparently issued by you on , has been dishonored. Pursuant to Mississippi law, you have fifteen (15) days from receipt of this notice to tender payment of the full amount of such check, draft, or order, plus a service charge of $40.00., the total amount due being $ . Unless this amount is paid in full within the time specified above, the holder may assume that you delivered the instrument with intent to defraud and may turn over the dishonored instrument and all other information relating to this incident to the proper authorities for criminal prosecution.

Yours truly,

*Use this form if the check was written on or after July 1, 2004.

ECONOMIC CRIME UNIT FOR BAD CHECKS (LOCATION)