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 MM slash DD slash YYYY Check Information:Check No.(Required)Date Passed(Required) MM slash DD slash YYYY 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) MM slash DD slash YYYY Signature(Required)
