WORTHLESS CHECK INFORMATION SHEET
Answer the below questions to see of you can send your returned check to theWorthless Check Unit:
Does this Complaint involve a POST-DATED check? YesNo Does this Complaint involve a TWO-PARTY check? YesNo Was PARTIAL PAYMENT received on this check? YesNo Was check deposited more than 30 Days after written? YesNo Did you agree HOLD this check? YesNo
A YES ANSWER INDICATES THAT THIS MATTER SHOULD BE HANDLED THROUGH THE APPROPRIATE CIVIL COURT, NOT THE WORTHLESS CHECK UNIT.   Please contact our office at specialservices@jccal.org or call us at 205-325-1422 if you have any questions regarding the appropriate civil court to pursue or need any other answers about this process.
INFORMATION REGARDING CHECK WRITER First Name : Middle Name : Last Name : Suffix : Address : City : State : Zip : --Select-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Phone No: Driver's License No : State Where Issuued : --Select-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming SSN : Date Of Birth : Race(if known): Sex: --Select-- White Black Hispanic Asian Other MaleFemale CHECK INFORMATION Check No : Date : Check Amount : Name of Person Accepting Check : Address of Person Accepting Check : Still Employed : YesNo Purpose of Check : Physical Location Where Check was Passed : --Select-- Wages Rent Merchandise Services Institute or Bank Check Drawn On : Check Returned : NSFClosed AccountOther VICTIM INFORMATION Victim or Business Name : Mailing Address : City : State : Zip : --Select-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Contact Name(please print) : Phone No : Fax No : Contact Email Address : Name of Person Who will Sign this Complaint : Magistrate Signature : Affiant Signature : Date :