FOR DA OFFICE USE ONLY Party Affidavit Dallas County

							                                                                                                 FOR DA OFFICE USE ONLY
                                                                                                 P.I.D. #: _________________
3rd Party Affidavit                                                                              PCT.#:   _________________


                                     Dallas County Theft by Check Complaint
                                        Issuance of Bad Check Complaint


In the name and by the authority of the STATE OF TEXAS PERSONALLY APPEARED
before me the undersigned authority this affiant, who after being duly sworn by me makes
the following statement under oath:

I have a good reason to believe and do believe that one ______________________________________________
Hereinafter styled Defendant, heretofore on or about the __________________________ day of ______ , 20 __ .
In the County of Dallas, State of Texas, did unlawfully and knowingly within the boundaries of
Justice of the Peace, Pct. _____ , of the said County and State, then and there issue and pass
to ___________________________________ , an agent of _________________________________________ ,
at the address of (street address, city & zip) ________________________________, located within the boundaries
of Pct. ____________________ , a check.


                                FACTS ABOUT THE ACCUSED (DEFENDANT)

Name of person who signed this check
____________________________________________________________________ ______________________
Address: _________________________ City: ___________ State:______ Zip: ____Phone: ________________
Sex: _______________ Ht: _______ Wt.:______ Eyes: _____ Hair: ______ DOB: _______ Race: __________
SSN: _____________________ TX/DL#: ______________ Amount of: __________ Check No: ___________
Date written:_________________________________ Acct. #:________________________________________
Location where check received (physical address):______________________________________________________
City: ____________________________________ County ____________ State: _________ Zip:____________
Check was received:                 From Accused               In Person      By Mail      Other
Check was exchanged for:            Property/Merchandise       Service        Other
Bank Returned Check Stamped:        NSF                       Account Closed  Stop Payment Other ________
Check was:                          Deposited w/in 30 Days                    Post Dated    A Held Check


                                                AFFIANT
                                 (The PERSON who is signing the Complaint Form)

Name:________________________________________ Business Name: ______________________________
Address: __________________________ City:__________________________ State: ______ Zip:__________
Home No.: ____________________________________ Business No.:_________________________________
Name of person who accepted/received check: _____________________________________________________
Was a drivers license and or other identification presented at time check was received? Yes___________No ___
If yes: ______________________________________________________________________________________


                                           INJURED PARTY
                          (The BUSINESS which suffered a loss of property or service)
Name___________________________________________Business Name: ________________________________
Home Address____________________________City________________________State_________Zip__________
Business Address__________________________City________________________State_________Zip__________
Home No.:_______________________________________Business No.:__________________________________
3rd Party Affidavit


                                        FACTS ABOUT THE RECIPIENT
                         (The PERSON who physically received and accepted the check DIRECTLY)

Name_____________________________________________________________________________________________
Home Address___________________________City_________________________State_________ Zip______________
Business Address_________________________City_________________________State_________ Zip______________
Home No.:___________________________________________Business No.:___________________________________


                                      FACTS ABOUT THE 3RD PARTY HOLDER
                             (The PERSON who physically received the check directly from payee)

Name:____________________________________________________________________________________________
Home Address: __________________________ City:_______________________ State: _________Zip:_____________
Business Address ________________________ City:_______________________ State: _________Zip:_____________
Home No.: __________________________________________ Business No.: __________________________________


Against the peace and dignity of the State.




_________________________________________                                             ______________________________________
Affiant/Complainant     (print)                                                           Affiant/Complainant    (signature)




Subscribed and sworn to before me on this _______ day of ______, 20_____.




                                                                              ___________________________________________________________
                                                                              Notary Public in and for the
                                                                              STATE OF TEXAS
                                                                              My Commission Expires: _____________________________________




__________________________________________________ ITEMS TO BE SUBMITTED WITH THIS COMPLAINT _________________________________________
   THE ORIGINAL CHECK             THE CERTIFIED LETTER OR GREEN CARD           RECEIPTS AND INVOICES             COPY OF DEMAND LETTER




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