OFFICIAL USE ONLY DO NOT WRITE IN THESE BOXES Assigned SPN Victims Name Assigned SPN Name and address for restitution corresp ID: 456542
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Please fill out this referral sheet below, affidavit, and witness list when referring worthless checks to the State Attorney's Office. Fill in all required areas. Do not write in the gray boxes. An affidavit is a legal WORTHLESS CHECK REFERRAL SHEET OFFICIAL USE ONLY DO NOT WRITE IN THESE BOXES Assigned SPN ____________________ Victim's Name ______________________ Assigned SPN ____________________ Name and address for restitution correspondence:__________________________________________________________________ Check Writer identification (SELECT ONLY ONE) : _____ Prior knowledge of or acquaintance with check writer _____ Personal recollection of the check writer at the time the check was received _____ Driver's License, ID card, or identifiers recorded on check by taker at time of receipt OFFICIAL USE ONLY - DO NOT WRITE BELOW THIS LINE PROSECUTABLE _____ DIVERSION ONLY _____ FELONY _____ MISDEMEANOR _____ GROUP # _____ VERIFYING INFO __________________________________________ REMARKS: _______________________________________________________________ ORTHLESS FFIDAVIT (Please type or print legibly) Checkwriter Name (as signed) _______________________________________DL# _____________________ State ____ Sex _____ Race_____ Date of Birth __________________________ Soc Sec # ___________-_________-___________ ___ City, ST, ZIP _______Home Ph. _______________________________________ Other Ph. _________________________________________ I, _________________________________________________ have reviewed this affidavit and do find there is probable cause to hold and bind over for trial the defendant named in this affidavit. ________________________________________________________________ ________________________________________________________________ DATE 11/25/08 WORTHLESS CHECK WITNESS FORMName: Sex: Race: DOB: _________ City: State Zip _______ Occupation:____________________ City: State Zip _______ Business Phone:___________________ ***************************************************************************************** PERSON WHO AUTHORIZED ACCEPTANCE OF THE CHECK: Sex: Race: DOB:__________ City: State Zip _______ Place of Employment: Occupation:____________________ Bus. Address: City: State Zip _______ Home Phone: Business Phone: ________________ ***************************************************************************************** PERSON WHO SENT THE 15-DAY LETTER Sex: Race: DOB:___________ Home Address: City: State Zip _______ Place of Employment: Occupation: __________________ Bus. Address: City: State Zip _______ Home Phone: Business Phone: ______________ Sex: Race: DOB: ____________ Home Address: City: State Zip _______ Place of Employment: Occupation:_______________ Bus. Address: City: State Zip _______ Home Phone: Business Phone:_________________ ****************************************************************************************** OTHER WITNESS: Sex: Race: DOB: _____________ Home Address: City: State Zip _______ Place of Employment: Occupation: ________________ Bus. Address: City: State Zip _______ Home Phone: Business Phone:_________________ ******************************************************************************************* OTHER WITNESS: Sex: Race: DOB: ____________ Home Address: State Zip _______ Place of Employment: Occupation: ________________ Bus. Address: City: State Zip _______ Business Phone: __________________