PROBABLE CAUSE STATEMENT I________________________________, upon my oath and under penalties of perjury, state as (Person filling out form) follows: 1. I have probable cause to believe that_________________________committed one or (Person who signed check) more criminal offenses. 2. The facts supporting this belief are as follows: _________________________________(Name on Check) wrote, made, passed (Circle one) check number_______, drawn on____________________(Name of Bank), payable to______________________________, in the amount of _______________________. This occurred in Greene County, Missouri. This check was returned from the bank unpaid, marked________________________(Reason for non-payment) and has not been paid at this time. I, knowing that false statements on this form are punishable by law, hereby affirm that the above information is true and accurate to the best of my knowledge, information and belief. _____________________________ Print Name _____________________________ Signature American LegalNet, Inc. www.FormsWorkflow.com