Please fill out the following blanks completely. It is very important that we have
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
Did the checkwriter present the check in person?
Did you see the checkwriter sign the check?
Do you know the checkwriter by sight or by name?
If so, please explain:
How did the bank stamp the check indicating their reason for dishonor?
Refer to Maker
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 date (MM/DD/YY)
Check Amount (##,###.##)
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?
Did you allow the checkwriter to post-date the check?
have a credit relationship with the checkwriter or the checkwriter’s company?
Did you get the merchandise back?
Has the checkwriter made any restitution?
If so, how much?
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