Free Bad Check Complaint Form - Nevada

Bad Check/Marker Complaint Form Clark County District Attorney
Bad Check Diversion Unit 200 Lewis Avenue #00246, Las Vegas, NV 89101 (702) 671-4701 Fax (702) 455-6410
Any "yes" answer indicates that this matter should be handled through the appropriate civil courts. Yes No



Does this complaint involve a post-dated check? Does this complaint involve a two party check? Was partial payment received on this account? Does this complaint involve an extension of credit?

DA's Office Use Only

Case # Information Regarding Issuer

First Name: SSN: Address 1: Address 2: City: Phone #: Picture ID Type: Passport #:

Middle Name: Date of Birth:

Last Name: Race: (if known)

Suffix (if any):

Female

Male

State: Driver's License #: ID #: Country:

Zip:

Country: State Where Issued: State Where Issued: Hair: Eyes: Height: Weight:

Check/Marker Information
Check/Marker #: Date: Check/Marker Amount: Returned Item Fee: Certified Mail Costs: Still Employed: Name & Address of Person Accepting Check/Marker: Purpose of Check/Marker (required):
(wages, rent, merchandise, services, gaming, etc.)

yes

no

Physical location where check was passed: Institute or Bank Check Drawn On: Account number:

** Attach original check/marker here **

Victim Information
Victim or Business Name: Mailing Address: City: Contact Name (please print) Contact E-mail Address: State: Phone #: Zip Fax #: Corporate Name (if different):

I (WE) hereby authorize the Clark County District Attorney or his designee as my agent to endorse and cash any negotiable instrument tendered by or on behalf of the drawer of the check presented for collection by this request and to obtain any bank or financial institution information regarding the drawer of this check to which we may be entitled. I (WE) hereby certify that all information in this complaint is true and accurate to the best of my knowledge.

X

Signature:

Print Name:

Date:

*Complaint must be signed and dated when submitted

Additional Information Needed from Gaming Establishments for Prosecution
Credit Application
Name on Credit Application: Does applicant speak English? Yes If not, did someone help him fill out form? Name of person helping: City: State: No Yes No

Residential Address Listed on Credit Application:

Zip:

Business Address Listed on Credit Application:

City:

State:

Zip:

Bank Accounts to Be Used by Casino for Redemption/Submittal Business Bank: Account Personal Bank: Account Bank: Other Account Bank: Other Account Date of Application: Date photo taken: Fingerprint or thumbprint on application yes Casino Employee(s) taking above information:
Account Number: Account Number: Account Number: Account Number:

Date information last updated:

or
no

Government Issued Photo ID Used (type & number): Fingerprint or thumbprint on marker(s) or check(s)

yes

no

Please attach copy of application and documentation of any phone calls or correspondence to and from customer regarding markers.

Markers & Checks
Date(s) marker(s) or check(s) signed: Witnesses observing and/or involved with the process of customer signing marker(s) or check(s) Title: Did he/she observe marker being signed? Name: Title: Did he/she observe marker being signed? Name: Title Did he/she observe marker being signed? What is the casino's normal course of business (disposition) agreed to on redeeming/submitting marker for this person: Name:

yes no yes no yes no

On checkout

7 days

15 days

30 days

60 days

90 days

Other (explain)
Who approved change:

If no, why not? Was the normal course yes of business followed in no this case? Was there an agreement to discount losses?

If yes, by whom & in what amounts:

yes

no Miscellaneous Information

If customer Arrival date: Departure date: stayed at hotel Number of times Past Were previous markers redeemed stayed/played Playing by customer or submitted to bank? History at hotel/casino: Have you received notice of any bankruptcy proceedings regarding these markers?

Paid Complimentary
redeemed submitted
Name of host(s) who deal with customer:

Names of Persons Contacting Customer Regarding these Markers or Checks
Person: Person: Person: Date: Date: Date: What was said: What was said: What was said:

Please attach additional sheets as needed and provide all applicable documents to disclose full information about this case.