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WORTHLESS CHECK INFORMATION DUSTY GALLIVAN ECTOR COUNTY ATTORNEY Check Writer Information Name Address Driver s License State Sex Home Phone Work Date Letter sent to check writer by regular mail DOB Merchant Information Business Number Manager Business Address Mailing address for restitution Cashier s name who took the check Cashier s address What was purchased with the check Has partial payment been accepted YES NO Amount My signature below CERTIFIES that I fully understand and assert the truth of the following facts concerning my complaint 1. The County Attorney s Of ce assumes FULL control and disposition of this case. 2. Upon collection of restitution or conviction check s are retained by the County Attorney as part of this of ce and WILL NOT be returned to the payee of this check. 3. After the ling of this check s restitution CANNOT be accepted by anyone other than this of ce. Article 31. 06 of the Texas Penal Code states A complaining witness commits an offense if after criminal proceedings have been instituted he solicits accepts or agrees to accept any bene t in consideration for abstaining from discontinuing or delaying the prosecution of another for any offense 4. I understand that if charges are led a warrant will be issued for the maker of the check and it is my responsibility as the complainant or person accepting the check to identify if necessary the maker in a court of law. 5. Although we attempt to collect restitution the County Attorney s Of ce is not a collection agency. 7. The check was thought to be good when taken* 8. The check was passed in ECTOR COUNTY TEXAS* 9. The check was NOT a hold check or post-dated check. 10. The check was deposited within 30 days of receipt. 11. The check WAS NOT a payment on account. 12. Restitution or partial payment has not been paid on this check except as indicated above and no property has been returned* 13. I further certify that this business displays on its premises notice that the business collects a check collection fee Merchant Fee in the amount of. However I understand that the Ector County Attorney will not collect a Merchant Fee in excess of 30. 00. 14. It is my responsibility to notify the County Attorney s Of ce of any change in my address change in ownership or other appropriate recipient for restitution herein* I hereby swear that the above information is true and correct to the best of my personal knowledge and belief* Complainant Subscribed and Sworn before me on this the day of Notary Public State of Texas For County Use Only PID Check ID. The County Attorney s Of ce assumes FULL control and disposition of this case. 2. Upon collection of restitution or conviction check s are retained by the County Attorney as part of this of ce and WILL NOT be returned to the payee of this check. 3. After the ling of this check s restitution CANNOT be accepted by anyone other than this of ce. Article 31. 3. After the ling of this check s restitution CANNOT be accepted by anyone other than this of ce. Article 31. 06 of the Texas Penal Code states A complaining witness commits an offense if after criminal proceedings have been instituted he solicits accepts or agrees to accept any bene t in consideration for abstaining from discontinuing or delaying the prosecution of another for any offense 4..

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