BAD CHECK CRIME REPORT TO
DAVE PATTON, BUENA VISTA COUNTY ATTORNEY
Send Report to: 606 Geneseo Street, Storm Lake, Iowa 50588 (712) 732-1933
PLEASE ANSWER THE FOLLOWING QUESTIONS, PRINT ALL INFORMATION IN INK AND SIGN BELOW
1. Was check post-dated at time of acceptance?
__Yes
__No
2. Was check received in the mail?
__Yes
__No
3. Does this matter involve a two-party check?
__Yes
__No
4. Were you asked to hold or delay depositing the check (s)?
__Yes
__No
5. Was there an open line of credit or payment on the account?
__Yes
__No
A “YES” answer to any of the above questions indicates this is a CIVIL matter and is not eligible for filing with the County Attorney.
Please contact the nearest small claims court for instructions on how to proceed with a civil case. If all boxes were checked “No”,
we’ll be happy to help. Please complete this report, date and sign it, and forward to the above address along with the 4 requested
attachments.
A “Statutory Notice” (see sample notice on reverse side) MUST be served to the check writer by U.S. Certified Mail, Sheriff
or private process server. On what date did you send notice? ____________ (please attach documentation).
Certified mail fees, Sheriff or Process Server Fees: $_________________Returned Item Fees: $________________
1. SUSPECT
__________________________________________________________________________________________
Check writer’s full name as written on check
________________________________________________________________________
Address
_______________________________________________________________________
City
State
Zip
Home Phone #
Other Phone #
_______________________________________________________________________
Driver’s License #
State
Expiration Date
How did you obtain the check writer’s identification?
2. CHECKS
Other ID
Was a photo ID obtained? __Yes
__Driver’s License
__Check Cashing Card________________
Check #
Amount
Date Received
What was check for?
__No
__Other______________________
Person accepting check
Can person ID
check writer ?
_________________________________________________________________________________________
1.
2.
3.
List additional checks on another form and attach.
3. VICTIM
__________________________________________________________________________________________
Victim / Firm Name
Phone
__________________________________________________________________________________________
Victim Address
City
State
Zip
__________________________________________________________________________________________
Name of person filing
Phone
__________________________________________________________________________________________
Address where check was accepted (if different from above address)
I UNDERSTAND THAT I MUST NOT ACCEPT RESTITUTION FROM THE CHECK WRITER AFTER FILING THIS
REPORT. INITIAL HERE: ______________
I HAVE READ ALL FILING INSTRUCTIONS, AND HEREBY CERTIFY UNDER PENALTY OF PERJURY, THAT
ALL INFORMATION IN THIS REPORT IS TRUE TO THE BEST OF MY KNOWLEDGE:
_________________________________________
Signature of person filing
___________________________________
Print name
________
Date
FILING THE BAD CHECK CRIME REPORT:
In order for the Buena Vista County Attorney’s Office to assist in seeking full restitution in those
cases that meet the eligibility guidelines, and in order to appropriately punish the check writer
please take the steps listed below. Note that although the County Attorney’s Office will seek full
restitution for victims whenever possible, this office is a prosecuting agency, not a collection agency, and
makes no recovery guarantees. “Restitution” refers to the face value of all checks listed in the report,
along with all reasonable “returned item” charges as determined by the court (a copy of the bank NSF
charge must be included as well as the Sheriff’s return of service).
A. Fill out form completely. Attach (1) bad checks and all of the following supporting
documents: (2) CERTIFIED MAIL RETURN RECEIPT or SHERIFF’S RETURN OF SERVICE, (3) Copy
of “STATUTORY NOTICE” and (4) “RETURNED ITEM” notices from the bank (with fees). Copy all
information for your records.
B. Mail this form and items (1) through (4) above directly to Buena Vista County Attorney
(address listed below).
C. Once a report has been filed: ALL restitution payments must be coordinated by the
Buena Vista County Attorney’s Office. Should the check writer contact you to make payment, direct them
to the County Attorney’s Office at 712-732-1933.
AFTER FILING:
A. If you do not receive restitution within 60 days, contact the County Attorney’s Office.
B. If restitution is not received from the check writer, your report 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
report is not prosecutable, the check(s) will be returned at your request.
SAMPLE “STATUTORY NOTICE”
Date
Dear Check Writer:
You are hereby notified that a check numbered ________ in the face amount of $ ________ issued by you on
_________ drawn upon ____________________ bank, and payable to __________________________ has
been dishonored. In accordance with Iowa 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 $20.00 plus certified mail or service fees, 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 Buena Vista County Attorney
for criminal prosecution.
Closing,
Your name
Address
Mail BAD CHECK CRIME REPORT and all other correspondence to:
DAVE PATTON, BUENA VISTA COUNTY ATTORNEY
606 GENESEO STREET, STORM LAKE, IOWA 50588