READ THIS EXAMPLE FULLY BEFORE COMPLETING THE AFFIDAVIT FORM

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READ THIS EXAMPLE FULLY BEFORE COMPLETING THE AFFIDAVIT FORM Powered By Docstoc
					      READ THIS EXAMPLE FULLY BEFORE COMPLETING THE AFFIDAVIT FORM
Name of Checkwriter (as signed):                          AS IT APPEARS ON CHECK                    Sex        M/F      Race      W/B/H/O
*Height                     *Weight              *Date       of Birth       M/D/Y           Hair                      Eyes              Soc
Sec #           -       -              Driver's Lic #                                                          State             Address:
     AS IT APPEARS ON THE IMPRINTED CHECK                             Home Ph.                     Bus Ph.                       Employer
                                  Bus Address                                                                  *     GIVE APPROX HEIGHT,
WEIGHT AND AGE (IN DOB SPACE) IF ACCEPTOR CAN IDENTIFY WRITER
***********************************************************************************************
The UNDERSIGNED, UNDER OATH, STATES ....

Check #                        in the amount of $                                date    DATE ON CHECK             and made payable to
                                   and drawn on the account number                                                                       of
NAME OF BANK                           was received on (date)             DATE WRITER GAVE YOU THE CHECK                and was returned
for the following reason:               NSF (        ),    ACCT CLOSED (          ),     NO ACCT (        ),       STOP PAYMENT (       ),
UNCOLLECTED FUNDS (          ),    REFER TO MAKER (        ),   OTHER (    )                                    AND WAS RECEIVED FOR:
 PAYMENT ON ACCT/DEBT (           ),   RENT (   ),    WAGES (     ),     CASH (     ),   MERCHANDISE (         ), or SERVICES (     ).

1.        City      and       County    where        check      was     received                               BOTH     ARE     IMPORTANT

2.   Was the check post dated? (dated ahead)                 . . . . . . . . . . . . . . .           YES ___           NO ___
3.   Were you asked to hold or delay deposit? . . . . . . . . . . . . . . .                          YES ___           NO ___

4.   Was the check delivered personally by checkwriter? . . . . . . . . . .                          YES ___           NO ___
5.   Was the check delivered by a person other than checkwriter?. . . . . .                          YES ___           NO ___
     (If yes, give name and address)

6.   Was the check sent by mail?. . . . . . . . . . . . . . . . . . . . . .                          YES ___           NO ___

7.   Did checkwriter sign an order or contract for which the mailed
     check was payment? (If yes, attach copy). . . . . . . . . . . . . . .   YES ___                                   NO ___
     ** ANSWER ABOVE YES ONLY IF THE CHECK WAS RECEIVED BY MAIL, ELSE ANSWER NO **
8.   Was a certified letter mailed to the checkwriter? . . . . . . . . . .                           YES ___           NO ___
     (If yes, attach copy of letter, postal receipt, or undelivered letter)
9.   Can the person who accepted the check identify checkwriter?. . . . . .                          YES ___           NO ___
10. Do you have a check cashing card for the checkwriter?                        . . . . . . . .     YES ___           NO ___
    (If yes, card #                                 )

11. Was the check cashing card # recorded on the check?                     . . . . . . . . .        YES ___           NO ___
12. Did the person accepting the check initial the check?                        . . . . . . . .     YES ___           NO ___

13. Was a photograph made of the person writing the check? . . . . . . . .                           YES ___           NO ___

14. Have you ever received a bad check from the person before? . . . . . .  YES ___                                    NO ___
    (If yes, how many times?            )
    ** ANSWER YES TO THE ABOVE ONLY IF CHECKS RECEIVED PRIOR TO THIS INCIDENT.
       OTHER CHECKS RECEIVED DURING THIS SAME PERIOD OF TIME DO NOT COUNT **

 SIGNATURE              OF                           PERSON                WHO              ACCEPTED                               CHECK
Signature of Complainant                                        Business Name & Title of Complainant

                                                                                                                                 Home
Address                                                    Business Address                          Phone No.

                                                 AFFIDAVIT MUST BE NOTARIZED
     BCDP18.2 (09/94)

				
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