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CheckFraud

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  • pg 1
									                              WORTHLESS CHECK AFFIDAVIT (SWORN COMPLAINT)
                                          (Please type or print legibly)
                                                          IDENTIFICATION

Checkwriter:________________________________________________________________________________________________
               Last                    First                     Middle
Address: ______________________________________________________________________Home Phone (     )____________
        Street or P.O. Box #    City              State                  Zip
Date of Birth:__________________ Sex:_____          Race:_______         Height:_______       SSN:___________________________
FL. Drivers License No./or ID:________________________________State:_______ Other Picture ID:__________________________
Place of Employment:__________________________________________ Work Phone (                  )_____________________________
1. Can you personally recognize the checkwriter?                                                                    (   ) YES   (   ) NO
2. Was the identity of the checkwriter verified via DL/photo i.d. when the check was presented?                     (   ) YES   (   ) NO
3. Was a photograph made of the person writing the check?                                                           (   ) YES   (   ) NO
4. Was the checkwriter a minor (under 18)?                                                                          (   ) YES   (   ) NO


A. City and County where check was received __________________________________________________________
B. Check No. _________ in the amount of $           dated _______________received on _________________ made payable to:
      _______________________________ drawn on the account of ___________________________________________
   Name of Bank _____________________________________ Account No. __________________________________
C. Returned for: ( ) INSUFFICIENT FUNDS ( ) ACCOUNT CLOSED ( ) STOP PAYMENT ( ) OTHER
   and was received for:
   ( )PAYMENT ON ACCOUNT/DEBT ( )CASH                ( )MERCHANDISE ( )SERVICES
   ( )OTHER (Please describe)_______________________________________________________________________________
D. Was the check postdated (dated ahead)?                                                             ( ) YES ( ) NO
E. Did you agree to accept it postdated?                                                              ( ) YES ( ) NO
F.   Were you asked to hold or delay deposit?                                                                       (   ) YES   ( ) NO
G.   How was the check received? ( )In person   ( )Mail   ( )Delivered
     If the check was delivered by a person other than the checkwriter give that person’s name and address:
      ____________________________________________________________ ________________________________________
H.   Did the checkwriter sign an order or contract for which the check was payment?         (If yes, attach a copy with signatures.)
I.   Defendant has _____ has not_____been sent the Statutory Notice by :
           ______ certified/registered mail (please attach return receipt/green card) OR by
           ______ 1st class US Mail (attach Affidavit of 1 st Class Mail Service).
     **At least fifteen days have passed since the Statutory Notice was mailed (attach copy of notice)**
J.   If the notice was returned by the Post Office, please attach a copy of the envelope.


              I SWEAR OR AFFIRM THE ABOVE INFORMATION IS TRUE TO THE BES T OF MY KNOWLEDGE.

     ________________________________________                        _____________________________________________
          SIGNATURE OF COMPLAINANT                                             PRINTED NAME OF COMPLAINANT

     _________________________________________________________________________________________
     NAME OF BUSINESS / TITLE OF COMPLAINANT / ADDRESS OF BUSINESS / TELEPHONE NO.


                                    The foregoing instrument was acknowledged before me this _____ day of
STATE OF FLORIDA                    _________________, 20_____ by __________________________________________________,
COUNTY OF_______________            who is personally known to me or who has produced ____________________________ as
                                    identification and who did take an oath.

            (SEAL)
                                                               __________________________________________
                                                               Notary Public
                            WORTHLESS CHECK WITNESS FORM


PERSON WHO ACCEPTED THE CHECK FROM THE CHECKWRITER:
Name:_________________________________ Address:___________________________________________
Home Phone :(___)_____________________ Business Phone :( ___) _____________________
Date of Birth:___________________________ Race:____ Sex:____
Occupation:__________________________________________________ Employee Number:____________
___________________________________________________________________________________________

PERSON THAT SENT STATUTORY NOTICE FOR THE VICTIM/BUSINESS:
Name:_________________________________ Address:___________________________________________
Home Phone :(___)_____________________ Business Phone :( ___) _____________________
Date of Birth:___________________________ Race:____ Sex:____
Occupation:__________________________________________________

CUSTODIAN OF THE RECORDS (PERSON WHO HAS ORIGINAL CHECK):
Name:_________________________________ Address:___________________________________________
Home Phone :(___)_____________________ Business Phone :( ___) _____________________
Date of Birth:___________________________ Race:____ Sex:____
Occupation:__________________________________________________




INSTRUCTIONS:

1. This form must be filled out completely.
2. One affidavit must be prepared for each check.
3. Attach the original worthless check affidavit and one copy (front and back) must be filed with the state
   attorney's office.
4. Attach two clear copies of the check (front and back).
5. Attach a copy of the statutory notice and the return receipt (green card), if sent certified/registered mail
   or attach the affidavit of 1st class mail service, if sent first class mail. If the notice was returned
   unclaimed, please provide the envelope indicating such, as stamped by the post office. Please note that
   the statutory notice does not have to be sent if the check was returned stamped “account closed” or no
   account found.”
6. Attach one copy of the application for check cashing card (if applicable) which bears the signature of
   the checkwriter.




       Rev. 09/2004
                     FILING YOUR COMPLAINT

Forms for filing your complaint will be provided by this office. The forms

may be copied for possible future returned checks. You must have the

following documentation when filing your complaint:

      1. Original and one (1) copy of the completed Worthless Check

         Affidavit (sworn complaint) form which has been notarized.

      2. Two (2) readable copies of the check (front and back).

      3. One (1) copy of the original contract, lease agreement, order or

         request for services of the check writer (if applicable).

      4. A copy of the Statutory Notice and the return (green card) if sent

         certified/registered mail or the affidavit of First-Class Mail Service

         if sent first class mail. If the notice was returned please provide

         the envelope indicating such as stamped by the Post Office. Please

         note that the Statutory Notice does not have to be sent if the check

         was returned stamped “Account Closed” or “No Account Found.”

      5. Please provide all other written documentation that you may have

         concerning the returned check.

      6. Photograph of check writer, if taken.
                                           STATUTORY NOTICE

DATE: _____________________________________

TO:    _____________________________________ (Check Signer)
       _____________________________________ (Name of Business, if applicable)
       _____________________________________ (Address)
       _____________________________________ (Address)

      You are hereby notified that a check, numbered               , issued by you on              , drawn upon
__________________________ Bank, and payable to                                         , has been dishonored.

        Pursuant to Florida law, you have 15 days from the date of this notice to tender payment of the face
amount of such check, $__________________, plus a service charge of $________________,
                 $25 if check is not more than $50.00;
                 $30 if check is more than $50.00 but not more than $300.00;
                 $40 if check is more than $300.00 but not more than $800.00; or
                 5% of value of check if over $800.00.
Thus, the total amount due is $                                  dollars and        cents.

        Unless this amount is paid in full within the time specified above, the holder of such check may turn
over the dishonored check and all other available information relating to this incident to the State Attorney for
criminal prosecution. You may be additionally liable in a civil action for triple the amount of the check, but in
no case less than $50.00, together with the amount of the check, a service charge, court costs, reasonable
attorney fees, and incurred bank fees, as provided in Florida Statute 68.065.

        I CERTIFY that the original of the statutory notice was mailed by US Mail, postage prepaid, to the
person (check writer) at the address indicated above.

                                              Sincerely,
                                              ______________________________________(Victim or Agent)
                                              _____________________________________(Name of Business)
                                              ___________________________________________(Address)
                                              ___________________________________________(Address)
                                              ______________________________________(Phone Numbers)
The above form has been approved by the State Attorney, 8th Judicial Circuit. This form should be
completed by the holder of the worthless check. It should be mailed to the person who signed the check at
the address printed on the check, or given at the time of issuance of the check (unless otherwise explained),
by first class mail, postage prepaid. A copy of this Notice should be retained and delivered to the State
Attorney’s Office together with the Affidavit of Mailing, the Worthless Check Affidavit (Complaint), and
readable copies of the front & back of the check if not paid within fifteen (15) days of the mailing of this
Statutory Notice. Please also attach the envelope if Notice was returned undeliverable by the Post Office.
                    AFFIDAVIT OF FIRST-CLASS MAIL SERVICE

I, ___________________________, either on my own behalf or as a representative of
___________________________________, hereby swear and/or otherwise affirm that a
notice pursuant to Ch. 832.07(1)(a), Florida Statut es, a copy of which is attached to this
Affidavit, has been sent to
__________________________________________________________________
at _____________________________________________________________________,
by first-class United States Mail, and swear or affirm that the address to which the notice
was sent was the address on the worthless check or an address taken from the writer of
the check on the date that the check was issued to myself or the company that I represent.
Or, if a different address was used, I’ve furnished an explanation below.

I further swear or affirm that at least fifteen (15) days have passed since the notice was
mailed to the writer of the check at the above- listed address.

SIGNATURE OF AFFIANT:
______________________________________________________

PRINT NAME:
________________________________________________________________
ADDRESS:
__________________________________________________________________

PHONE:
____________________________________________________________________

STATE OF _____________________

COUNTY OF ___________________

The foregoing instrument was acknowledged before me this____ day of
__________________, 20___ by _________________________________, who is
personally known to me or who has produced ___________________________ as
identification.


(seal)


_____________________________________________Notary Public

								
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