DISTRICT COURT OF MARYLAND FOR LOCATED AT (COURT ADDRESS) DISTRICT COURT CASE NUMBER (City/County) RELATED CASES: COMPLAINANT/APPLICANT Printed Name Address City, State, Zip Agency, sub-agency, and I.D. # (Officer Only) Telephone Printed Name Address City, State, Zip DEFENDANT Telephone CC# Sex Other Race D.O.B Ht ID Wt DEFENDANT'S DESCRIPTION: Driver's License # Hair Eyes Complexion APPLICATION FOR STATEMENT OF CHARGES FOR BAD CHECK I, the undersigned, apply for statement of charges or warrant which may lead to the arrest of the above named Defendant because on or about Date at Place , the above named Defendant 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): presented to (full legal name of business or person): Said check was returned from bank marked: REGISTERED LETTER SENT (date): on (date) RETURNED MARKED: Payable to: Drawn by: Check No: having a value of $ (Continued on attached pages) (DC-CR-044A) I solemnly affirm under the penalties of perjury that the contents of this Application are true to the best of my knowledge, information, and belief. Date Officer's Signature Printed Name I have read or had read to me and I understand the Notice on the back of this form. Date Applicant's Signature Printed Name Subscribed and sworn to before me this Time: at AM day of Month , I.D. Number Year PM Judge/Commissioner I understand that a charging document will be issued and that I must appear for trial on Date , when notified by the Clerk, at the court location shown at the top of this form. Time I have advised applicant of shielding right. Applicant declines shielding. I declined to issue a charging document because of lack of probable cause. Date Applicant's Signature Commissioner I.D. Number TRACKING NUMBER DC-CR-044 (Rev. 07/2016) American LegalNet, Inc. www.FormsWorkFlow.com NOTICE TO APPLICANT FOR A CHARGING DOCUMENT You are making an application for a charging document which may lead to the arrest and detention of the individual you are charging. If, as result of your application, a charging document is issued by the commissioner, it will not be possible for the commissioner to withdraw the document. The charge may only be disposed of by trial or by action of the State's Attorney. You will be required to appear at the trial as a witness. Failure to appear on the date set by the court could result in your arrest for failure to obey a court order. The application which you are filing is being filed under oath. Criminal Law Article � 9-503, of the Annotated Code of Maryland provides that any person who makes a false statement or report of a crime or causes such a false report or statement to be made to any official or agency of this State, knowing the same, or any material part thereof, to be false and with intent that such official or agency investigate, consider or take action in connection with such statement or report, shall be subject to a fine of not more than $500, or be imprisoned not more than six months, or be both fined and imprisoned, in the discretion of the court. It is essential that you furnish as much information as possible about the offense. To be sure that your information is adequate, your application should clearly state the following: 1. WHO? Identify the accused, (the person you are complaining about), and identify yourself. 2. WHEN? The time, day, month and year of the offense. 3. WHERE? The exact address and street, the city, county and state where the offense happened. Also state whether the offense happened in a private home or in some public place. 4. WHAT? State exactly what was done to you. For example: if property was taken, describe it and its value; or, if property was damaged or destroyed, indicate the original cost of the item or its replacement value. If you do not know the exact value, estimate it as accurately as possible. 5. WHY? The facts you give must show the accused intended to commit a criminal act. 6. HOW? How the accused committed the offense. For example, if you were physically assaulted, were you struck with a fist, a flat hand, kicked, or pushed, or were you struck with an object, such as a club or pipe, etc.? If property was taken, how did the accused get it? If it was destroyed or damaged, how did the accused cause the damage? 7. At the top of the application, you will notice a space marked "DESCRIPTION". The information in this space refers to the accused. It is important that you furnish as much of this as possible so that the accused may be easily identified. If you need further assistance in completing your application, please feel free to ask the commissioner. You are entitled to request that address and telephone number of a victim, a complainant, or a witness be considered for shielding at the filing of this application. NOTICE: Remote access to the name, address, telephone number, date of birth, e-mail address, and place of employment of a victim or non-party witness is blocked. (Md Rule 16-909) American LegalNet, Inc. www.FormsWorkFlow.com