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OFFICE OF THE DISTRICT ATTORNEY
ELEVENTH JUDICIAL DISTRICT
CHECK OFFENSE REPORT FORM
THIS FORM MUST BE COMPLETED IN ITS ENTIRETY
VICTIM
CONTACT PERSON
ADDRESS
P.O. BOX
CITY, STATE, ZIP
PHONE
NAME AND ADDRESS OF PERSON WHO ACCEPTED CHECK
| CHECK NUMBER |
DATE WRITTEN |
AMOUNT OF CHECK |
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| Please complete the following
--- check YES or No as applicable |
YES |
NO |
| Is this a stop payment check? |
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| Was the check post-dated? |
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| Was partial payment accepted? |
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| Was check received in payment of an
account? |
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| Was there an agreement to hold the
check? |
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| Is this a two party check? |
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| Has this check been presented twice
to the bank for payment? |
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What was received in exchange for the check?
Please explain all attempts made to contact the issuer of the check and their
response
Signature________________________________________Dated_______________________
If mailing, please be sure to enclose all copies of pertinent documents
and the ORIGINAL CHECK.
MAIL TO:
CHECK FRAUD UNIT
OFFICE OF THE DISTRICT ATTORNEY
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136 JUSTICE CENTER RD. SUITE 203
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(FOR CHAFFEE COUNTY:
7405 W. HWY 50)
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CANON CITY, CO 81212
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(FOR CHAFFEE COUNTY:
SALIDA, CO 81212)
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