Please fill out the following blanks completely. It is very important that we have
all
of the information requested! If you have more than one check from the same person, please fill out the form for one check, email it to us, then go back and change any necessary information for the second check and email that one, and so on until information on all checks has been emailed to us.
Checkwriter's last name
Checkwriter's first and middle name(s)
Checkwriter's Street Address
Checkwriter's City, State zip
Checkwriter's Driver's License
State
Race:
Gender:
Hair Color
Eye Color
Did the checkwriter present the check in person?
Yes
No
Did you see the checkwriter sign the check?
Yes
No
Do you know the checkwriter by sight or by name?
Yes
No
If so, please explain:
How did the bank stamp the check indicating their reason for dishonor?
NSF(Insufficient Funds)
Account Closed
Refer to Maker
Uncollected Funds
Stop Payment
On what bank was the check drawn?
What name is printed at the top of the check?
Routing and account numbers from the bottom of the check
Check Number
Check date (MM/DD/YY)
Check Amount (##,###.##)
If
Property
was stolen:
What was stolen?
When was it stolen?
Address where property was stolen
Did you agree to hold the check before taking it to the bank?
Yes
No
Did you allow the checkwriter to post-date the check?
Yes
No
Did you
ever
have a credit relationship with the checkwriter or the checkwriter’s company?
Yes
No
Did you get the merchandise back?
Has the checkwriter made any restitution?
Yes
No
If so, how much?
If
Service
was stolen:
Who performed the service?
Address where service was performed
Date when service(s) performed
Describe (in detail) the services that were stolen.
Please provide us any additional information about the theft that you think will be helpful to our
investigation.