SCA-M333: Criminal Complaint-Worthless Check Revision Date: 3/7/2019; WVSCA Approved: 3/7/2019; Docket Code(s): MWICC Page 1 of 2 IN THE MAGISTRATE COURT OF COUNTY, WEST VIRGINIAState of West Virginiav. Case No.Defendant (full name) City, State & Zip Code Social Security NumberXXX-XX- / / Date of BirthAddress Phone Number(s)Driver's License / Identification Number CRIMINAL COMPLAINT: WORTHLESS CHECK[W. Va. Code 247 61-3-39f, 61-3-39a Issuing worthless check to satisfy pre-existing debt.] I, the undersigned complainant, upon my oath or affirmation, state the following to be true and correct to thebest of my knowledge and belief. On, inWest Virginia, the defendant did issue and deliver toa check, draft, or order for the payment of money when the defendant did not have sufficient funds on deposit in or credit with this bank with which to pay the check, draft, or order upon presentation, in violation of W. Va. Code 24761-3-39a. The check, draft, or order which is enclosed with this complaint, contains the following information: Complainant's Signaturehas not / Complainant's Name (full name) Complainant's Address Complainant's Phone Number(s)County,Date: No. / / Bank Name: $ Pay to the Order of: For: I further state that:1. Notice of the dishonored check, draft, or orderhas been sent by certified mail to the defendant. [If notice was sent by the complainant, proof of mailing must accompany this complaint. Such proof is either the certified mail return receipt or the actual mailed notice showing that the notice was returned undelivered or returned refused.] 2. When accepted, the aforesaid check, draft, or order was not post-dated and I was not expressly notified nor did I have any other reason to believe that the check, draft, or order would be dishonored. 3. I request that a warrant issue for the arrest of the defendant. Supplemental information regarding the identity of the above-named defendant and/or a service charge levied for the is / dishonored check, draft, or orderis not attached. This information is given under oath or affirmation and is incorporated herein by reference.Subscribed, sworn or affirmed before me and signed in my presence, this day of , 20. My commission expires on . Signature/Title / / American LegalNet, Inc. www.FormsWorkFlow.com SCA-M333: Criminal Complaint-Worthless Check Revision Date: 3/7/2019; WVSCA Approved: 3/7/2019; Docket Code(s): MWICC Page 2 of 2 Case No.A. The following supplemental information regarding the defendant in the above-referenced case(s) is offered pursuant to W. Va. Code 247 61-3-39f(b) and (c). Business Address: Mailing Address (if different from the home or business address indicated previously): Place of Employment: Work Phone: Race: Sex: Height:B. A service charge of $ has been imposed or collected by my financial institution in connection with the check, draft, or order described in this complaint.ft.,in. American LegalNet, Inc. www.FormsWorkFlow.com