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Missoula County Attorney
(406)258-4737
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Missoula County - County Attorney

Department: Missoula County Attorney
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Missoula County Attorney - Bad Check Form B

Form B

(Staple check here.)

BAD CHECK INFORMATION

Today's Date:____________________

Victim Information

NAME:
Address:

Email:_________________________________

Taker of Checks:_________________________
Position:_______________________________

Can taker of check identify check writer?   Yes_______    No________

Has any restitution been taken on this check, or merchandise returned?  Yes $________  No _________

Has demand letter been sent; certified mail card returned?  Yes _________ No __________

Check Writer Information

NAME:
Address:

Email:_________________________________

Phone Number: (___) ____________________
Place of Employment:_______________________________

Age: _________
Sex: _________

Other:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Check Information

Date:_________________________

Check Number:_________________

Bank:_________________________

NSF______________ Account Closed______________

Account Number:_______________________________

Driver's License Number:________________________________________

Birth Date:_______________________________________________

Social Security Number:___________________________________