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Driver’s License # State Check writer’s full name as written on check BAD CHECK COMPLAINT FORM PETER CARLISLE PROSECUTING ATTORNEY FILE COMPLAINT FORMS BY MAIL TO: P.O. Box 2950, Honolulu, HI 96820-1650 (postal address only - not a walk-in office) VICTIM HOTLINE: 1-800-842-0698 REFER CHECK WRITERS TO: 1-800-832-9973 DATE RECEIVED : COMPLAINT #: P L E A S E P R I N T A L L I N F O R M A T I O N I N I N K A N D S I G N O N R E V E R S E S I D E Address (s) 1 SUSPECT SS # Sex Date of Birth Age Height Hair Eyes Weight Yes No 2 CHECKS Name of person filing Phone Victim / Firm Name Phone 3 VICTIM Victim Address City State Zip Address where check was accepted if different from the above address How did you obtain the check writer’s identification ? Drivers License Police Report #_________________) Check Cashing Other _________________________ Was the check handed to you by someone other than check writer? Yes No Name: Address: Staple Documents Here Employer (if known) Business Phone Business Address List Additional Checks On Another Form And Attach Yes No Yes No Yes No Yes No What did you write on the check at the time you received it? Drivers License # Check–Cashing Card # Your initials or identification # Other _____________________________________ Has the check writer been notified that the check (s) has been dishonored? Yes No If so, how? Certified Mail Phone Other If other, describe: Return Item Fees: Certified Mail Fees: A“YES” answer to any of the above questions indicates this is a CIVIL matter and is therefore ineligible for the Bad Check Restitution Program. It should be dealt with through small claims court, or turned over for private collection, do not proceed with filing a complaint. If all questions were answered “NO”, you may file a bad check complaint by completing the front and back side of this form. 1. Was check post-dated at time of acceptance? Yes No 4. Were you asked to hold or delay depositing the check (s)? Yes No 2. Was check received in the mail? Yes No 5. Was there an open line of credit or payment on the account? Yes No 3. Does this matter involve a two-party check? Yes No TO DETERMINE WHETHER YOUR COMPLAINT MAY BE ACCEPTED AS A CRIMINAL MATTER, ANSWER THE FOLLOWING QUESTIONS: IMPORTANT: FOLLOW REQUIREMENTS ON THE REVERSE SIDE OF THIS FORM City State Zip Home Phone # Other Phone # Check # Date Received Amount What was check for ? Person Accepting Check Can person ID check writer ? 4/4/03 I understand that I must NOT accept restitution from the check writer after filing this complaint with the Bad Check Program. Initial here _________________ I HAVE READ ALL FILING INSTRUCTIONS, AND HEREBY CERTIFY UNDER PENALTY OF PERJURY, THAT ALL INFORMATION IN THIS COMPLAINT IS TRUE TO THE BEST OF MY KNOWLEDGE. BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBB Signature of Person Filing Print Name Date Filed HONOLULU COUNTY PROSECUTING ATTORNEY BAD CHECK RESTITUTION PROGRAM P.O. Box 29250 Honolulu, HI 96820-1650 (postal address only) (Not walk in office) V VICTIM HOTLINE (800) 842-0698 3. AFTER FILING: A. If you do not receive restitution within 60 days, contact the Prosecuting Attorney Bad Check Restitution Program. B. If restitution is not received from the check writer, your complaint will be evaluated for criminal prosecution. C. IF PROSECUTABLE, YOU WILL NOT RECEIVE FURTHER NOTICE UNTIL THE SUSPECT HAS BEEN ARRAIGNED IN COURT. This office will retain all checks as a matter of official record. If for some reason the complaint is not prosecutable, the check (s) will be returned at your request for civil collection purposes. Date Dear Check Writer: You are hereby notified that a check num- bered _____ in the face amount of $______, issued by you on ______ drawn upon _______ bank, and payable to _________, has been dishonored. Pursuant to Hawai- ian law you have 10 days from receipt of this notice to tender payment of the full amount of such check plus a service charge of $25, the total amount due being $____ . Unless this amount is paid in full within the time specified above, the holder of such check may turn over the dishonored check and all other available information relating to this incident to the Prosecuting Attorney for criminal prosecution. Closing, Your name address SAMPLE “COURTESY NOTICE” Victims of bad checks may file a complaint form with the Honolulu County Prosecuting Attorney Bad Check Restitution Program, provided there is sufficient information, and that the case meets all eligibility guidelines. The Prosecuting Attorney’s office will seek full restitution for victims wherever possible; however, please keep in mind that this office is a prosecuting agency and therefore can make no collection guarantees. “Restitution” refers to the face value of all checks listed in the complaint, along with all reasonable “returned item” charges assessed by the bank (a copy of the bank NSF charge must be included). MAIL ALL CORRESPONDENCE TO: 1. PRIOR TO FILING A BAD CHECK COMPLAINT: A. Was a “Courtesy Notice” sent to the check writer via U.S. Certified Mail (return receipt and restricted delivery requested), allowing a ten day grace period to pay off the check (s). See sample notice Yes No If no, why not? B. Was photo identification (i.e. driver’s license, state I.D., check cashing card number, etc.) recorded at the time the check was passed. Yes No If no, why not? C. Have you filed this check (s) with a debt collection agency or other debt collector? Yes No If Yes, provide the name and phone # And have you cancelled the debt with the agency? Yes No 2. FILING THE COMPLAINT FORM: A. FILL OUT FORM COMPLETELY. Attach checks and all supporting documents such as CERTIFIED MAIL RETURN RECEIPT OR UNDELIVERED LETTER, COPY OF “COURTESY NOTICE”, “RETURNED ITEM” NOTICES FROM THE BANK (WITH FEES). COPY ALL INFORMATION FOR YOUR RECORDS. B. Mail this form directly to Honolulu County Prosecuting Attorney Bad Check Restitution Program. Address listed here C. Once a complaint has been filed: ALL restitution payments must be collected by the Bad Check Restitution Program. Should the check writer contact you to make payment, direct them to the Bad Check Restitution Program. (See contact information).
