Free CRIMINALCOMPLAINT-WORTHLESS CHECK (SCA-M333) - West Virginia

IN THE MAGISTRATE COURT OF
STATE OF WEST VIRGINIA v.

COUNTY, WEST VIRGINIA

Case No(s).: Defendant Address Telephone Driver s License No. Social Security No. Date of Birth

CRIMINAL COMPLAINT: WORTHLESS CHECK [ W. Va. Code § 61-3-39a]
I, the undersigned complainant, upon my oath or affirmation, state the following to be true and correct to the best of my knowledge and belief. On in (date) County, West Virginia, the defendant did issue and deliver to a check (described below) for the payment of money when the defendant did not have sufficient funds on deposit in or credit with this bank with which to pay the check upon presentation, in violation of W. Va. Code § 61-3-39a. The above referenced check, which is enclosed with this complaint, contains the following information: Date: Bank Name: Pay to the Order of: $ Dollars For: I further state that: 1. Notice of the dishonored check (check one) has not has been sent by certified mail to the defendant. [If notice was sent by the complainant, proof of mailing must accompany this complaint. Such proof is either the certified mail return receipt or the actual mailed notice showing that the notice was returned undelivered or returned refused.] When accepted, the aforesaid check was not post-dated and I was not expressly notified nor did I have any other reason to believe that the check would be dishonored. I request that a warrant issue for the arrest of the defendant. No.

2.

3.

Supplemental information regarding the identity of the above-named defendant and/or a service charge levied for the dishonored check (check one) is is not attached. This information is given under oath or affirmation and is incorporated herein by reference. Complainant s Name Complainant s Telephone Complainant s Address Complainant s Signature day of .

Subscribed, sworn or affirmed before me and signed in my presence, this Signature/Title

My Commission expires (if applicable):
Return Defendant File Complainant Prosecutor

W. Va. Code § 61-3-39f SCA-M333-1 / 5-98

WORTHLESS CHECK COMPLAINT CASE NO(S).

A. The following supplemental information regarding the defendant in the above-referenced case(s) is offered pursuant to W. Va. Code § 61-3-39f (b) and (c):

Business address:

Mailing address (if different from the home or business address indicated previously):

Place of employment:

Work phone:

Race: B. A service charge of $ described in this complaint.

Sex:

Height:

has been imposed or collected by my financial institution in connection with the check

W. Va. Code § 61-3-39f SCA-M333-2 / 5-98

Return Defendant File Complainant Prosecutor