Kern County District Attorneys Office

Bad Check Report

INSTRUCTIONS: Complete one Bad Check Report for each check writer. You may include up to six checks by the same check writer on each report. Staple original check(s) to the back of the Bad Check Report.
MAIL TO: District Attorney's Office
Checkbusters
P. O. Box 2327
Bakersfield, CA 93303 		OR BRING TO: District Attorney's Office
Checkbusters
1300 18th Street, Suite F
Bakersfield, CA 93301
Telephone: (661) 868-8500
Fax: (661) 868-8575
For Office use only:
Case #:        Client #:
Date:       Bank Code:
At the time of acceptance of the check(s), did you (or your employee) obtain the following information? Note any change in check writer's home and/or work address or telephone number.
(Note: Check(s) must have been received for goods, services or cash.)
Full Name of Check Writer:
Driver's license or DMV ID No.:
Street Address/P.O. Box:
City:
State:      ZIP:   
Home Phone No.:
Business Address/P.O. Box:
Business Phone No.:
Other Address/P.O. Box:
The information came from: check(s)
file and referred to on check(s)
not recorded.
The person that actually received the check (witness):
Name:
Street Address/P.O. Box:
City:
State:      ZIP:   
Phone No.:

Yes or No
       The person who received check(s) witnessed the check writer's signature or endorsement.
       The person who received check(s) initialed the check(s) as evidence of witnessing signature.
       Did the person who accepted the check(s) know the check writer?
       Can the person who accepted the check(s) identify the check writer?
Victim Information:
Full Name:
Street Address/P.O. Box:
City:
State:      ZIP:   
Phone No.:
Location check(s) were received if different from above:
Street Address/P.O. Box:
City:
State:      ZIP:   
Check(s) Information:
Check number amount $
Check number amount $
Check number amount $
Check number amount $
Check number amount $
Check number amount $
If efforts were made to contact the writer of the check(s), please list dates, methods and results:
The check(s) in question is/are submitted for criminal prosecution. By submitting this check(s) for prosecution. I agree NOT to accept restitution from the check writer or his/her agent. I certify that this report is true, accurate and complete to the best of my knowledge.
Date: Signature:_________________________________
Name, address and phone of person filing report:
Full Name:
Street Address/P.O. Box:
City:
State:      ZIP:   
Phone No.: