Bad Check Repayment Form - Hancock County Prosecutor

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Age

Phone*

Email

Social Security Number or Driver's License Number

Description of incident*

Who sent notice to payer?*

Was notice sent by certified mail?*

Yes
No

Amount of check*

Date on check*

Check was payable to*

Bad check draw on (date)*

Where was check cashed?*

Was check post dated?*

Yes
No

Is this a third-party check?*

Yes
No

Was there an agreement to hold the check for cashing at a later date?*

Yes
No

What was said about the check at the time it was presented?*

What was obtained with the check?*

Have any payments been received on the check since non-payment by the bank?*

Yes
No

The above information is true as best I recall or am reliably informed. I will sign criminal charges against check maker, and testify in court, whether the check is made good (by payment) or not, and will report all other information I receive, to assist prosecution. Entering your name below will qualify as an electronic signature.*

Signer's title

Signer's phone*

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