Bad Check Crime Reporting Online Report Bad Check Crime Report Victim/Merchant Name:(Required)Contact Name:(Required) First Last TitleVictim Contact Information:Email Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Check Writer's Information:Check Writer's Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Phone(Required)Driver's License NumberStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDate of Birth Check Information:Check No.(Required)Date Passed(Required) Face Value of Check(Required)Name of Person Accepting Check(Required) First Last Can person ID check writer?(Required) Yes No MoreIs a notice of your service fee conspicuously displayed on your premises?(Required) Yes No What is the service fee on your notice?Address where check was accepted (if different than Victim/Merchant address) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code DocumentsThe following documents must be submitted for the report to be processed.Copy of the returned check(Required)Max. file size: 2 GB. Copy of the courtesy notice(Required)Max. file size: 2 GB. Proof the notice was sent U.S. Certified Mail(Required)Max. file size: 2 GB. Additional InformationDo you have additional information?By signing and submitting this report you acknowledge the following(Required) I agree• I will not accept direct payment from the check writer after filing this report with the Bad Check Diversionary Program, unless notified an agreement is entered into. • I understand that the check writer has the option to dispute this claim in writing with the Bad Check Diversionary Program. • If this crime report is not completely filled out it the may be rejected and returned. • I attest that I have sent courtesy notice to the check writer via U.S. Certified Mail including return receipt and after 10 days it remains unpaid. • I have reviewed the filing instructions, I hereby affirm and attest under penalty of perjury, that all information provided on this crime report is true to the best of my knowledge. Name of Person Filing(Required)Date Filed(Required) Signature(Required)
