DISTRICT COURT OF MARYLAND FOR (City/County) LOCATED AT (COURT ADDRESS) DISTRICT COURT CASE NUMBER DEFENDANT'S NAME (LAST, FIRST, M.I.) CONTINUATION SHEET - BAD CHECK CHARGE APPLICATION FOR STATEMENT OF CHARGES/STATEMENT OF PROBABLE CAUSE On or about (date) Did unlawfully obtain from (full legal name of business or person): by uttering a certain bad check dated: ACCOUNT NO: on the (name/address of bank): in the sum of $ presented to (full legal name of business or person): Said check was returned from bank marked: REGISTERED LETTER SENT (Date): At (place) Having a value of $ Check No. Drawn By: Payable to: on (date) RETURNED MARKED: On or about (date) Did unlawfully obtain from (full legal name of business or person): by uttering a certain bad check dated: ACCOUNT NO: on the (name/address of bank): in the sum of $ presented to (full legal name of business or person): Said check was returned from bank marked: REGISTERED LETTER SENT (Date): At (place) Having a value of $ Check No. Drawn By: Payable to: on (date) RETURNED MARKED: Date Applicant's Signature Printed Name TRACKING NUMBER DC-CR-044A (Rev. 05/2015) American LegalNet, Inc. www.FormsWorkFlow.com