Staple check to form				       Form B 
					        Bad Check Information



Date:____________

     Victim Information	          		   Check Writer Information		     Check Information


Name:_____________________________	Name:_____________________________	Date:_____________________________
Address:__________________________	Address:__________________________	Check #:__________________________    
					Amount: $_________________________
e-mail:___________________________	 
Taker of check:___________________      Phone #: (___)__________		Bank:_____________________________		
										    
Position:_________________________	Place of Employment:		
									 	NSF___   Acct. Closed _____
Can taker of check identify
check writer?				Age: ______				Account #_______________
  Yes _____    No ______		Sex: ______				
										Driver’s license number:
Has any restitution been 		Other:_____________________________
taken on this check, or 		___________________________________						
merchandise returned?			___________________________________	Birth date:_______________
  Yes  $_________    No ___		___________________________________				
					___________________________________	Social Security Number:
Has demand letter been		 	___________________________________		
sent; certified mail card 		___________________________________	________________________
returned?								
    Yes ___   No  ____



               ***********************************************************************************************


Staple check here


Date:____________

     Victim Information	          		   Check Writer Information		     Check Information


Name:_____________________________	Name:_____________________________	Date:_____________________________
Address:__________________________	Address:__________________________	Check #:__________________________    
					Amount: $_________________________
e-mail:___________________________  
Taker of check:___________________      Phone #: (___)__________		Bank:_____________________________		
										    
Position:_________________________	Place of Employment:		
									 	NSF___   Acct. Closed _____
Can taker of check identify
check writer?				Age: ______				Account #_______________
  Yes _____    No ______		Sex: ______				
										Driver’s license number:
Has any restitution been 		Other:_____________________________
taken on this check, or 		___________________________________						
merchandise returned?			___________________________________	Birth date:_______________
  Yes  $_________    No ___		___________________________________				
					___________________________________	Social Security Number:
Has demand letter been		 	___________________________________		
sent; certified mail card 		___________________________________	________________________
returned?								
    Yes ___   No  ____