Old Town Police Department Bad Check Packet

A. Report

1. Your business name and address: ______________________________

2. Person making report: ______________________________

3. Have you successfully served a 5-day statutory bad check notice on the passer?  YES   NO
If yes, how? Certified Mail   Personal Service
If not served, the reason why: __________________________________________________

B. Check Information

1. Check Number: _______________

Date check was accepted: _______________

Amount of check: _______________

2. Name of the person who presented the check: ______________________________________

C. The person who actually took the check must complete the next section

1. Your name: __________________________________________

2. Description of the person passing the check:

________________________________________________________________________

________________________________________________________________________

3. Name given by the passer: ___________________________________

Address and Phone Number: ___________________________________

4. Did you know the passer?   YES    NO

If yes, how? _______________________________________________

5. Can you identify the passer?    YES   NO

If yes, how? ________________________________________________

6. Did you see the passer write the check and/or endorse the check?   YES   NO

7. Did you initial, mark upon or write upon the check at the time you accepted it?   YES   NO

If yes, what? _______________________________________________

D. To be Completed by the Person Making the Report

1. Please explain what steps you or your employees have taken to contact the suspect and/or recover your losses:

________________________________________________________________________

________________________________________________________________________