GREENE COUNTY PROSECUTING ATTORNEY BAD CHECK DIVISION 1010 BOONVILLE, SPRINGFIELD, MISSOURI 65802 1.BUSINESS OR PERSON DEFRAUDED- 2. PERSON WHO SIGNED CHECK- NAME___________________________________________________ NAME ________________________________________________________ ADDRESS________________________________________________ ADDRESS______________________________________________________ CITY, STATE & ZIP________________________________________ CITY, STATE & ZIP______________________________________________ PHONE (_____)___________________________________________ 3. PERSON ACCEPTING CHECK- NAME______________________________________________________________ Business is required to maintain contact with/current address of witness 4. Can witness identify check writer? Yes No 5. Was driver’s license shown? Yes No 6. Did ID match check writer? Yes No 7. License or I.D.#__________________State of Issuance_____ Birth Date________ 8. Check #___________Date Check Passed____________Amount of Check_______ 9. What did check writer purchase with check?___________________________________ 10. Was check post-dated? Yes Was partial payment accepted? Yes Was there agreement to hold check? Yes Was the check a two-party check? Yes Did the check require 2 signatures? Yes Was the check presented in Greene Cty? Yes Was the check passed in person by the signer?Yes Is this a payroll check? Yes No No No No No No No No 11.Prosecution of checks under $500.00 must commence within one year of being passed. Checks within 90 days of that date cannot be accepted. 12. I understand the purpose of this complaint is to initiate criminal prosecution. My sole purpose is to prosecute the check writer and agree to cooperate with this prosecution until completed. Signature of person completing form Date .............................................................................................................................................. | | | | | PLACE ORIGINAL CHECK HERE | | | | (STAPLE CHECK AT RIGHT MARGIN OR FORM) | | | | | ........................................................................................................................................... Attach Probable Cause Statement and 10 day letter (required for stop payment complaints) to back American LegalNet, Inc. www.FormsWorkflow.com