BAD CHECK APPLICATION 1. Maker of the Check Address Phone DOB SOCIAL SECURITY NUMBER: RACE HAIR EYES HEIGHT WEIGHT I.D. Marks; scars, glasses, etc. 2. PAYEE (Victim) Agent/Manager Address Phone 3. 4. 5. Amount of Check $ Date of Check Date you mailed letter? Was the letter sent certified? YES Date you received Check? NO or regular mail 6. 7. If the certified letter was signed for, what was the date letter was signed? Was the letter returned to you unclaimed, or was it received by the addressee? Unclaimed Claimed Was the check presented to the Bank within 30 days of being received? Yes No What consideration was given to the Maker of the check in exchange for the payee to take the check? Example (goods, food, services, etc.) Did exchange of check occur at the same time? Yes No 8. 9. 10. 11. Was Identification produced and documented on the check? Yes No Did the person receiving the check know the maker of the check by name? Yes No Who received the check? Did the person who passed the check do any of the following in the presence of the person who accepted the check? Date Check Sign Check Why was the check returned to the victim? Insufficient Funds Account Closed 12. 13. 14. 15. Other The above answers are true to the best of my knowledge and belief. Signature Date American LegalNet, Inc. www.FormsWorkFlow.com