3. The Check Writer must NOT have asked the acceptor to HOLD or DELAY DEPOSIT of the check, even for a very brief period of time.



Similar documents
The Pima County Attorney s Office Bad Check Program Guidebook

BURNET COUNTY ATTORNEY S OFFICE Don't Get Burned By A Hot Check

WORTHLESS CHECK DIVERSION PROGRAM

UINTA COUNTY, WYOMING DATASHEET NSF/ACCOUNT CLOSED CHECK REPORTING PACKET

Gila County Attorney s Office Bad Check Program Guidebook

Hot Check Program 4. INFORMATION TO RECORD ON THE FRONT OF THE CHECK: REMEMBER, always record all information on the front of the check.

ONEIDA COUNTY DISTRICT ATTORNEY WORTHLESS CHECK DIVERSION PROGRAM RESTITUTION GUIDE FOR MERCHANTS AND RESIDENTS

Diversion/Accountability Worthless Check Program RESTITUTION GUIDE FOR MERCHANTS AND RESIDENTS

HUBBARD COUNTY CHECK DIVERSION PROGRAM

CHECK ENFORCEMENT GUIDEBOOK. Maricopa County PROGRAM. Attorney s Office. Where to submit a bad check. Bill Montgomery. Page 1

PROCEDURES FOR CRIMINAL & CIVIL PROSECUTIONS OF DEPOSIT ACCOUNT FRAUD, BAD CHECKS

TROY POLICE DEPARTMENT MERCHANTS GUIDE BAD CHECKS Page 1 of 13

Polk County Attorney s Office

McLEOD COUNTY DISHONORED CHECKS PACKET

The Morrison County Attorney s Office

**Additional information may be requested at the discretion of the Board.**

OFFICE OF THE DISTRICT ATTORNEY Third Judicial District Of Kansas Chadwick J. Taylor, District Attorney

NAVAJO COUNTY ATTORNEY S OFFICE

Oklahoma Board of Dentistry

Kentucky Motor Vehicle Commission SALESPERSON LICENSE APPLICATION IMPORTANT NOTICE REGARDING ALL SALES PERSONNEL

APPLICATION FOR DOMESTIC RECIPROCITY LICENSE. The State Board of Cosmetology may grant license by reciprocity, without examination, if:

Please contact if you have additional questions regarding your claim.

Certified Process Server APPLICANT CHECKLIST

CITIZENS AND BUSINESSES OF ST. CHARLES COUNTY:

Instructions for Sealing a Criminal Record. (Expungement)

Michael Gayoso, Jr. Office of the County Attorney TH

GEORGIA BOARD OF PHARMACY 2 Peachtree Street, N.W. 36 th Floor Atlanta, Georgia 30303

BAIL BOND LICENSE APPLICATION FOR CORPORATE SURETY OF:

Deposit Account Fraud / Bad Check Guide

CLASS A LICENSE RENEWAL APPLICATION

Private Protective Services - Contract Security Company Application, Page 1

How to Use the California Identity Theft Registry

Edina Police Department 4801 W. 50 th Street Edina, MN EMERGENCY (Police, Fire, Ambulance)

PIERCE COUNTY DISTRICT COURT 930 TACOMA AVE S, Room 239, TACOMA, Small Claims Information

RHODE ISLAND DEPARTMENT OF LABOR AND TRAINING DIVISION OF WORKFORCE REGULATION AND SAFETY PROFESSIONAL REGULTION UNIT

HOW TO FILE A PETITION TO EXPUNGE JUVENILE OFFENSES

INSTRUCTIONS FOR COMPLETING DBPR ABT 6006 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO APPLICATION FOR CIGAR WHOLESALE DEALER PERMIT

STATE OF KANSAS OFFICE OF THE ATTORNEY GENERAL Through the KANSAS BUREAU OF INVESTIGATION INSTRUCTIONS

Grandparent s Power of Attorney Information and Forms

Greenlee County Attorney

IDENTITY THEFT PACKET

CORPORATE SURETY LICENSE APPLICATION

Hempfield Township Board of Supervisors

South Carolina Department of Insurance Professional Bondsman / Runner / Surety Bondsman License Application

Instructions for Pistol Permit Applicants. If you have any questions call

CERTIFICATE OF REHAB. & PARDON INSTRUCTION FORMS PACKET

How to Clear an Arrest from Your Record in Texas (Expunction)

Huron County Juvenile Court

San Antonio Police Department FORGERY DETAIL 315 S. Santa Rosa SAN ANTONIO, TX (210) OFFICE (210) FAX

REQUIREMENTS WHEN FILING COMPLAINT

APPLICATION FOR NATIONAL EXAMINATION IN MARITAL & FAMILY THERAPY

Solicitor Permit Application

MARYLAND IDENTITY THEFT RANKING BY STATE: Rank 10, 85.8 Complaints Per 100,000 Population, 4821 Complaints (2007) Updated January 29, 2009

ELEVENTH JUDICIAL CIRCUIT OF FLORIDA APPLICATION FOR CERTIFICATION OF SPECIAL ASSISTANT PUBLIC DEFENDER

Identity Theft Information and Affidavit

Grandparent Power of Attorney (POA) Checklist

Private Process Server Program Application Requirements

26 th Judicial District SelfServe Center NAME CHANGE ADULT

INSTRUCTIONS PETITION FOR EXPUNGEMENT OF CRIMINAL RECORDS PROVIDED UNDER W.VA. CODE

APPLICATION FOR LICENSE PRACTICE OF MASSAGE THERAPY

When should these forms be used?

APPLICATION FOR RESTRICTED DENTAL LICENSE NON-REFUNDABLE APPLICATION FEE $200 WELL-BEING PROGRAM FEE $25

CITY OF LITTLE CANADA APPLICATION FOR MASSAGE THERAPY ESTABLISHMENT LICENSE

1611 E. PFENNIG LN., P.O. BOX 679 PFLUGERVILLE, TEXAS PFLUGERVILLE POLICE DEPARTMENT INSTRUCTIONS

APPLICATION FOR INVOLUNTARY CUSTODY FOR MENTAL HEALTH EXAMINATION [West Virginia Code: ]

ROCKWALL POLICE DEPARTMENT CRIMINAL INVESTIGATIONS DIVISION 205 W. Rusk St. Rockwall, Texas (972)

OFFICE OF THE DISTRICT ATTORNEY Third Judicial District Of Kansas Chadwick J. Taylor, District Attorney

Notary Public Frequently Asked Questions

2. Present residence address no. street town state zip code. Mailing address, only if mail delivery is not available to residence address

How To File A Civil Suit In Texas

NC General Statutes - Chapter 15A Article 17 1

LICENSING PROCEDURES FOR LIFE SETTLEMENT BROKERS AND PROVIDERS

NEW/RENEWAL APPLICATION FOR PAIN MANAGEMENT CLINIC REGISTRATION

INFORMATION AND DOCUMENTATION REQUIRED FOR PETITION FOR UNCLAIMED FUNDS

MASSAGE THERAPY CERTIFICATE 2016 LICENSE APPLICATION INSTRUCTIONS City of Plymouth 3400 Plymouth Boulevard, Plymouth, MN

ALL LOAN BROKERS AND ORIGINATORS DOING BUSINESS IN INDIANA FROM: OFFICE OF SECRETARY OF STATE TODD ROKITA, SECURITIES DIVISION

City of Terrell Hills 5100 North New Braunfels Avenue San Antonio, Texas

Sec Certificates of use.

APPLICATION FOR PAYMENT FROM THE REAL ESTATE RECOVERY FUND FORM RF-107 GENERAL INFORMATION

PLEASE READ BEFORE COMPLETING APPLICATION

CHARTER SIGHTSEEING LICENSE APPLICATION

SELF-REPRESENTED LITIGANT PETITION FOR DIVORCE UNDER ARTICLE 103 (with no children)

For any questions contact: City Clerk Michelle Tesser Tel: Fax:

Quincy Police Department One Sea Street Quincy, MA (617) TTY: (617)

NOTICE TO GRANDPARENT

PRIVATE INVESTIGATOR APPLICANT INSTRUCTIONS

Leander Police Department 705 Leander Dr Leander, Texas (512)

ACCELERATED REHABILITATIVE DISPOSITION APPLICATION

York County Sheriff's Office Identity Theft Victim s Packet

EDEN PRAIRIE POLICE DEPARTMENT PROCEDURE PACKET. (Revised January 2016) Reporting Check & Financial Transaction Card Fraud

MINNESOTA BOARD OF PHYSICAL THERAPY

LICENSING PROCEDURES FOR VIATICAL SETTLEMENT BROKERS AND PROVIDERS

INSTRUCTIONS FOR SEALING/EXPUNGING AN ADULT CRIMINAL COURT RECORD

APPLICATION INSTRUCTIONS FOR LICENSED ALCOHOL AND DRUG ABUSE COUNSELOR (LADAC)

CERTIFICATE OF SEALING

STEP 5 - EDUCATION You must request Official Transcripts verifying your education, to be sent directly from your college or university.

APPLICATION FOR DUI COURT

SPECIAL VOLUNTEER DENTAL LICENSE WEST VIRGINIA BOARD OF DENTAL EXAMINERS APPLICATION

STATE OF NEVADA DEPARTMENT OF BUSINESS AND INDUSTRY REAL ESTATE DIVISION 2501 East Sahara Avenue, Suite 102 * Las Vegas, NV *(702)

COLORADO IDENTITY THEFT RANKING BY STATE: Rank 8, 89.0 Complaints Per 100,000 Population, 4328 Complaints (2007) Updated November 28, 2008

Transcription:

Procedures and Requirements for filing a Worthless Check Complaint with the Office of the State Attorney s Office, Broward County, Florida Phone 954-831-8444 1. The check must have been accepted in Broward County, Florida or mailed from Broward County. (if mailed the envelope with the post-marked is needed) 2. The check must NOT have been postdated. 3. The Check Writer must NOT have asked the acceptor to HOLD or DELAY DEPOSIT of the check, even for a very brief period of time. 4. There must not have been any reason for the acceptor to believe the check would not be honored. 5. Check must be stamped with the bank processing date and reason check was returned. (We accept NSF, Account Closed and Stop Payment check complaints only; any other reason must be explained in writing by the Check Writer s banks) 6. Sufficient information is required to identify Check Writer and must be written on the check at the time it is accepted: full name, sex, height, date of birth, race, home address, home, business telephone numbers, employer, copy of driver license, driver license number/identification card, state of issuance and membership card number. 7. This office strongly recommends that business establish procedures to ensure proof of identification such as a photocopying of driver license with check. Failure to do so may result in declining prosecution due to insufficient evidence. 8. Additional identifying information may be required in order to issue a summons: eye and hair color, social security number, weight, unusual physical features, passport number/country, business address. 9. Person accepting the check should initial or note his/her Employee ID number (if applicable) when it is accepted. 10. Person accepting the check from the Check Writer, (or some other witness) must be able to appear in court and positively identify the defendant or at least testify about a procedure used to ensure proper identification such as the attachment of photocopy of picture identification card or surveillance cameras. 11. We must receive the complaint through the method of case presentation listed below, and as soon as the time limitations on dishonored check letters have expired and at least (4) four months prior to the expiration of the statute of limitations indicated below:

Amount/Type of Check Degree of Check Method of Presentation $150.00 or more and good or services are rendered at the same time or after the check is received. 3 rd degree felony Felony, through Detective or Law Enforcement Officer from the Jurisdiction check was received or mailed from Statute of Limitations 3 years from the date check was written or delivered Less than $150.00 or goods and services are delivered rendered before the check is received. (in which case, the amount is irrelevant) 1 st degree misdemeanor Misdemeanor 2 years from the date the check was written or Less than $150.00 on which payment has been stopped, or involving any amount of pre-existing debt) 2 nd degree misdemeanor Misdemeanor 1 year from the date the check was written or delivered In certain instances you may wish to proceed civilly, see section 68.065, Florida Statute. In a civil action the maker of the check could be liable for triple the amount of the check, not to mention collection fees. If Maker of check offers restitution, do not agree to drop charges. The State may still pursue prosecution even if restitution is paid in part or in full.

MISDEMEANOR WORTHLESS CHECK is defined as a check returned to you from the bank stamped, Insufficient Funds, Stopped Payment and/or Account Closed and goods or services are rendered before the check is received, in which case the amount of the check is irrelevant. Wages, rent or any other contractual obligation usually are classified as a misdemeanor in the State of Florida. If your complaint is a misdemeanor: 1. No Police Report is necessary but always welcomed. 2. A dishonored check letter (Copy attached hereto), must be mailed by certified or registered, return receipt requested to the Check Writer of an Insufficient Fund worthless check per Florida Statute 832.27(1)(a). Your letter must be identical in wording to the attached letter and addressed to the Check Writer. (This letter is not required for Account Closed or Stop Payment checks) According to the Statute, this letter must be sent to the address of the Check Writer as shown on the check or to be a better, more current address, given at the time the check is issued. If a better address is discovered later, a copy of the letter should be sent to that address as well. (Keep a copy of all letter(s) ). 3. If the letter is returned to a you as unclaimed or if reimbursement is not received within seven (7) days of the signed return receipt, complete the Worthless Check Affidavit attached hereto. (Please write legibly in ink or type) Fill in all blanks and provide all requested information. If more than one person accepted checks from the same Check Writer, a separate affidavit must be completed by each acceptor. 4. Have the affidavits NOTARIZED by a Notary Public. (Under the penalties of perjury, your signature on the affidavit will declare that the facts stated in it are true pursuant to F.S. 92.525(2). 5. You can contact the State Attorney s Office to schedule an appointment or mail the completed notarized affidavits, along with a copy of the front and back of the check, worthless check letter, certified or registered return receipt or unopened envelope, copies of any contracts or invoices and Identification from yourself, such as a Driver License and/or State Identification Card, to the State Attorney s Office, at the address listed on the form attached hereto, indicating Attention: Case Filing. (Business with membership or check cashing cards must provide copy of card and/or photograph of suspect and application records) 6. We do not guarantee restitution; the objective of the Office of the State Attorney is to prosecute those who violate criminal statutes.

MISDEMEANOR WORTHLESS CHECK (CONT D) 7. It takes from approximately (3) three weeks to (2) two months for bank records to be received from the proper bank. Some banks are faster than others. Please contact this office within 4 weeks of the filing of your complaint for the status of your case. 8. If you are a retailer, please provide an affidavit from each person who received the worthless check. This affidavit should include details of the exchange and identification of the suspect. 9. Prior to presenting a complaint about a dishonored check to the Office of the State Attorney, you may place or assign the debt from the bad check to a private debt collector and any cost of this collection can be added to the cost of collecting this bad debt. 10. The debt collector shall have 90 days from the date of placement of the debt for collection. Upon the expiration of the ninety (90) days, and any extensions, you may present a complaint to for our office for interest, keeping in mind the applicable statut of limitations. 11. The standard that the State s Attorney s Office follows is mandated by the Florida Statutes and Case Law when deciding to file a criminal complaint is whether there is a reasonable likelihood of conviction before a jury requiring proof beyond a reasonable doubt. 12. If this office decides to file a criminal complaint, a Court Case Number and Judge will be assigned. A summons (notice to appear in court) will be issued by the Clerk of the Court to be served on the defendant by the Sheriff. (The Defendant will not usually be arrested. The case may take an extended period of time before resolution and it is the responsibility of the victim and/or witnesses to keep this office abreast of current telephone numbers and addresses. 13. A defendant who fails to appear for a court date after being charged with a Worthless Check charge, resulting in a Judge issuing a valid capias (warrant) and who a Judge issues a capias, shall have his or her Driver License suspended or revoked.

FELONY WORTHLESS CHECK is defined as a check returned to you from the bank stamped, Insufficient Funds, Stopped Payment, Account Closed for an amount of $150.00 or more given at the same time in exchange for goods or services or the goods or services are rendered after the check is received. 1. Follow Procedure Numbered two (2) as listed above. 2. Initiate a police report with your local Police Department or Sheriff s Department in the jurisdiction in which the check was passed/received. 3. That Police Department or Sheriff s Department will investigate, the matter and if sufficient evidence or a crime is obtained, they will present your case to the State Attorney s Office. A check for any amount written that is a forgery or counterfeit would be considered for review as a felony. STOP PAYMENT CHECKS It is a crime in Florida to stop payment on a check with intent to defraud. However, it is usually difficult to prove intent to defraud. The facts of the case must establish, beyond a reasonable doubt, that the purpose of the Stop Payment was fraudulent when the check was issued, as well as when payment was stopped, and must exclude the reasonable possibility of mere dissatisfaction with goods or services received on the part of the person who wrote the check. In a criminal case, reasonable doubt on this issue is resolved in favor of the person who wrote the check and will preclude in filing of criminal charges. The only legal recourse in such stop-payment cases is in the civil courts, either in County or Circuit Court, depending on the amount of the check. You should contact your Attorney for further information. If this is a misdemeanor complaint, follow procedures for Misdemeanor Worthless Check complaint and if a felony complaint, follow procedures under Felony Worthless Check.

WORTHLESS CHECK AFFIDAVIT INSTRUCTIONS Please read carefully and complete only area applicable to you. 1. Complete one affidavit for each check/document. 2. Answer every question. Criminal cases will not be filed with incomplete or illegible affidavits. 3. Identification blocks and Endorsement blocks should be read carefully and marked appropriately. 4. Facts not covered in the questionnaire portion of the affidavit should be noted on the last page. 5. All affidavits MUST BE NOTARIZED. 6. Attach a legible copy of all applicable items, clearly showing the front and back of the document(s), suspect photograph, invoices, bills, receipts, copy of driver license, bank card, bank surveillance photo(s), account history sheets, account signature cards and customer forgery affidavit, any overnight mail acceptance cards with name of person who signed for merchandise, to the affidavit. (If business has membership or check cashing card, provide copy of card and/or photograph and application records.) 7. Make a copy of the affidavit for your records. The original will be given to the Police Officer and or State Attorney s Office. Please include the following information in your affidavit: 1. Details about the transaction 2. How and where the check was received 3. Complete description and identity of individual who passed the check 4. Indicate if the person passing the check is different then the suspect listed on the suspect page 5. All information about the goods being exchanged for the check 6. All conversations concerning the quality of the goods made by the suspect before or after check was passed 7. Any other information that you feel is pertinent to this transaction

NOTICE OF DISHONORED CHECK Florida Statute 832 To: Dear : You are hereby notified that a check, numbered issued by you on drawn upon, and payable to, has been dishonored. Pursuant to Florida law you have seven (7) days from the date of this notice to tender payment of the full amount of such check plus a service charge of $25.00, if the face value of the check does not exceed $50.00, or $30.00, if the face value exceeds $50.00, but not exceed $300.00, or $40.00, if the face value exceeds $300.00 or an amount of up to five (5) percent of the face amount of the check, whichever is greater, the total amount due being $ and cents. Unless this amount is paid in full within the time specified above, the holder of such check may turn over this dishonored check and all other available information relating to this incident to the State Attorney for criminal prosecution. You may be additionally liable in a civil action for triple the amount of the check, but in no case less then $50.00, together with the amount of the check, a service charge, court costs, reasonable attorney fees and incurred bank fees, as provided in s. 68.065. Dated this day of 20 Yours truly,

NOTICE OF DISHONORED CHECK Florida Statute 832.07(1)(a) To: Dear : You are hereby notified that a check, numbered issued by you on drawn upon, and payable to, has been dishonored. Pursuant to Florida law you have fifteen (15) days from the date of this notice to tender payment of the full amount of such check plus a service charge of $25.00, if the face value of the check does not exceed $50.00, or $30.00, if the face value exceeds $50.00, but not exceed $300.00, or $40.00, if the face value exceeds $300.00 or an amount of up to five (5) percent of the face amount of the check, whichever is greater, the total amount due being $ and cents. Unless this amount is paid in full within the time specified above, the holder of such check may turn over this dishonored check and all other available information relating to this incident to the State Attorney for criminal prosecution. You may be additionally liable in a civil action for triple the amount of the check, but in no case less then $50.00, together with the amount of the check, a service charge, court costs, reasonable attorney fees and incurred bank fees. Dated this day of 20 Yours truly,

CITIZEN AFFIDAVIT I,, accepted the below listed document at on this date:, and can identify in a trial and photo lineup as the person who gave me the Document. Type of document:. MERCHANT AFFIDAVIT I,, employee for located at accepted the check listed below, while located at Zip code: Zip code: VICTIM / CHECK PAYEE Name: Company Name (if applicable): Address: City: State: Zip code: Day Time Telephone: Race: Sex: Collection Agency: CHECK WRITER INFORMATION Full Name (as on check): Address(s): City: State: Zip code: Home Phone: Other Phone: Alias(s) Names: Race: Sex: Age: Date of Birth: Height: Weight: Color Hair: Social Security: Passport #: Driver s License: State: Unusual Features: Employer: Address: How and where did you obtain the Check Writer s identification?: Driver s License Police Report Check Cashing Card Photograph Membership Card Other/Explain:

CHECK INFORMATION Amount of the Check: Date of Check: Check Number: Date Check Given: Exact Goods/Services Received for check: Below are some examples of Goods and Services, this is not an all-exclusive list: Cash, Wages, Rent, Merchandise, Initial Deposit/Rent, Payment on Account or Debt, Services/Note Type (e.g. medical, legal, installation, repair). Date Goods/Services Received: First Date Bank Processed Check: When did you learn check was no good?: Reason check returned: Type and degree of offense: 1. Was the check Postdated? No Yes 2. Were you asked to hold or delay deposit of the check? No Yes 3. Was the check delivered personally by Check writer? If delivered by a person other than the Check writer, give the name and address. Also, provide a notarized statement from that person. Other Person: Address: Other Information: 4. Did you write the Check writer ID information, required by F.S. 832.07(2)(B), on the check when you accepted? No Yes 5. Did you compare the picture on the identification to the person? No Yes 6. Are they positively the same person? No Yes 7. Does your business establishment have other means of identifying the suspect? If yes, what? 8. Did this person use any other means to identify himself? If so, what? No Yes, No Yes, 9. Would you be able to identify the person issuing the check from a police line-up? No Yes 10. Can you identify the Check writer? No Yes 11. Did Check writer have a check cashing/membership card with your business? No Yes

12. Did you initial or note your business ID name and number on the check? No Yes 13. Was the check mailed? No Yes 14. Was the Check sent by an overnight service? (UPS, Post office, Federal Express) Provide receipt indicating person who excepted. No Yes, 15. Did the Check writer sign and order/contract? No Yes 16. Was the check issued as payment of an existing debt. No Yes 17. Is there an invoice or receipt? (attach a copy) No Yes 18. Was a certified letter mailed to the Check writer? No Yes 19. Have you filed a complaint affidavit for worthless check before on this person? No Yes 20. Did you witness the person fill out the payee, amount, and date? No Yes 21. Did you witness the person fill out the payee, amount, and date? No Yes 22. Did you witness the person sign the front of the check when issued to you? No Yes 23. Did you witness the person endorse the check? (signature on the back) No Yes 24. If yes, please provide overnight express service receipt indicating person and company that accepted package. No Yes,

WITNESS(S) Person who accepted the check and who is signing this affidavit: Name: Address: City: State: Zipcode: Home Telephone: Business Telephone: Employer: Occupation: Can this person identify the Check presenter? Yes No Person who authorized acceptance of the check: Name: Address: City: State: Zipcode: Home Telephone: Employer: Business Telephone: Occupation: If victim is a business, please list person responsible for original records, ( records custodian ), which may be needed for court (e.g. check cashing, invoice or contract, membership card and photograph, etc.): Name: Address: City: State: Zipcode: Home Telephone: Business Telephone: Can testify to: Other Witness(s): Name: Address: City: State: Zipcode: Home Telephone: Employer: Business Telephone: Occupation: I the undersigned, under oath, state that the named Check writer did draw, make, utter or deliver a worthless check, the original submitted with affidavit, and that my answers to all questions in this affidavit are true and correct. SWORN TO AND SUBSCRIBED before me, this day of, A.D., by the Affiant herein, who is personally known to me who produced the following identification: Notary Public, State of Florida (Seal) Commission Expires

If mail, include the following: (form attached hereto list address for the Office of the State Attorney) Notarized check affidavit Copy of Worthless check letter Copy of Contracts/invoices Copy of Membership card/photo Copy of membership card records Copy of cashing card records Copy of front & back of check Copy of return receipt or unopened returned envelope Copy of State identification card or driver s license Copy of suspect driver s license Copy of check cashing card Bank, Citizen and Merchant PLEASE OUTLINE below everything that was discussed and the details about the transaction. (Include, as close to verbatim as possible, what each person stated/asked/answered) I certify this statement is true and correct to the best of my knowledge. Signature of affiant: SWORN TO AND SUBSCRIBED before me, this day of, A.D., by the Affiant herein, who is personally known to me who produced the following identification: Notary Public, State of Florida (Seal) Commission Expires

MICHAEL J. SATZ STATE ATTORNEY S OFFICE Seventeenth Judicial Circuit Of Florida Broward County Courthouse Worthless Check Unit 201 S.E. Sixth Street, Suite 720 Fort Lauderdale, Florida 33301-3360 A F F I D A V I T (Please PRINT all information except signature) Suspect s Name: Police Agency Offense Report #: State Attorney Office: Central North South West STATE OF FLORIDA ) COUNTY OF BROWARD PERSONALLY APPEARED BEFORE ME, the undersigned authority duly authorized to administer oaths and take acknowledgments, the AFFIANT herein, who, after having been duly sworn, deposes and says: 1. AFFIANT Name 2. AFFIANT Address ) SS: 3. On, the day of, A.D. 20, in Broward County, Florida: (If continued on second page, check here and sign below and on second page) AFFIANT SIGNATURE SWORN TO AND SUBSCRIBED before me, this day of, A.D., by the Affiant herein, who is personally known to me who produced the following identification: Notary Public, State of Florida (Seal) Commission Expires