Bad Check Complaint Form PDF Details

If you have been the victim of a bad check, you may be wondering what to do about it. The first step is to fill out a bad check complaint form. This form will provide the necessary information to begin the process of recovering your money. The form can be downloaded from our website, and instructions on how to complete it are included. If you have any questions, please don't hesitate to contact us. We're here to help!

Form NameBad Check Complaint Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesbad check los angeles, los angeles county bad check program, los angeles county bad check restituion program, bad check complaint los angeles county form

Form Preview Example





Confirm Eligibility


Bad Check Program Address:

Bad Check Program Contact:

P.O. Box 86407

(800) 842-0733

- Victim Hotline

Los Angeles, CA 90086-0407

(800) 269-0206

- Check Writer Hotline

For more information:


Was check post-dated at the time of acceptance?





Does this matter involve a two-party check?





Was check received as a payment on an loan account?





Were you asked to hold or delay depositing the check(s)?





Does the check involve an extension of credit?




* If any of the above are checked “Yes”, the check is ineligible for the program. See the back page for an ineligible list.


Victim/Merchant Name:__________________________________________________________________________________

2Contact Name: ____________________________________________ Title: ________________________________________


Victim Contact Information:

Email: ________________________________________________________





Email and/or fax are required for acknowledgement receipt of check and/or Program communication

Address:________________________________________City:______________________State:______Zip Code:____________

If assessed a bank charge(s) for the attached bad check(s) please state the amount of the bank charge per check

$_________________ (Per California Penal Code 1001.65 (c) you are eligible to be reimbursed up to $15 per check for assessed bank charges.)

Step Check Writer’s Name:_____________________________________________________

3Address:______________________________________________ Apt:______________


City:__________________________________ State:________ Zip Code:___________




Home Phone:(_____)__________________Other Phone:(_____)__________________

Driver’s License # / Other ID #:



Date of Birth:



Other ID: (if applicable)


check here

“Courtesy Notice” must be sent to recover the bad check(s) in question. If no attempt has been made, the check may not eligible for prosecution. ( See courtesy notice on back.)


Ck. No.


Date Passed $ Amount Name of person accepting check

What was the


Can the check








(if no longer employed please list manager)

Check for?


writer be identified?
















































































































Address where check was accepted (if different than Step 2):______________________________________________________ (Required)

City:________________________________________ State:_______ Zip Code:____________________

I will not accept direct payment from the check writer after filing this form with the Program. Please refer check writer to (800) 269-0206.


I understand that the check writer has the option to dispute this claim in writing with the Bad Check Program.



If this complaint form is not completely filled out it may prevent or delay this case from moving forward for prosecution review.

I attest that I have sent courtesy notice to the check writer and after 10 days it remains unpaid.



I have reviewed the filing instructions, I hereby affirm and attest under penalty of perjury, that all information provided on this complaint form is


true to the best of my knowledge.






Sign & date





Signature of Person Filing (Required)

Print Name of Person Filing

Date Filed

Staple original or bank-generated substitute

Additional complaint forms are available at:

For additional information and complaint forms:

Sample “Courtesy Notice”


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. You have 10 days from receipt of this notice to tender payment of the

full amount of such check plus a service charge of $_______, the total amount due being $_________.

Unless this amount is paid in full within the time specified above, we may turn over the dishonored check and all other available information relative to this incident to the District Attorney’s Office for potential criminal prosecution.


Your name/address

Bad Check Program Information

As a victim of a bad check you may file this form with the Los Angeles County District Attorney, provided there is sufficient information, and that the check meets all eligibility guidelines. The Los Angeles County District Attorney’s Office will seek full restitution for victims whenever possible; however, please keep in mind that the Bad Check Restitution Program can make no recovery guarantees. By submitting the check to the program you surrender control of the check to criminal process and forego the opportunity to pursue civil debt collections.

Check writers are encouraged to make payments in full. Should a partial payment be received, the payment will be allocated between the victim and the Bad Check Program. “Restitution” refers to the face value of all checks listed on this report along with all “stated” bank charges assessed by your bank.

The following types of checks are ineligible for the program:

*Two-party checks

*Partially re-paid checks

*Fraudulent or stamped lost/stolen/forged

*Payroll, credit card or rent checks

*Post/pre dated or altered checks

*Checks you agreed to hold before depositing

*Checks passed outside of Los Angeles County

*Checks which are repayment of loan or civil contract agreement

What to do after my complaint form is filed with the Program

Please do not accept direct payments from check writers. Should the check writer contact you to make payment, refer them to the Check Writer Hotline at (800) 269-0206

You may contact Victim Services for case updates at (800) 842-0733 anytime.

Please allow a minimum of 90 days to pursue restitution.

If the check writer does not comply with the Program, the case may be reviewed for possible criminal prosecution.

If we are unable to recover restitution and/or the check is not “eligible” for prosecution, you may request the check(s) be returned to pursue a civil remedy.

Filing Instructions

1.Fill out Complaint Form completely.

2.Attach checks or legal copies of all checks (front and back side of checks) and all supporting documents such as CERTIFIED MAIL RETURN RECEIPT OR UNDELIVERED LETTER, COPY OF “COURTESY NOTICE,” “RETURN ITEM” NOTICE FROM THE BANK (WITH FEES).

3.Mail Bad Check Complaint Form and all other correspondence to:

Los Angeles County Bad Check Restitution Program

P.O. Box 86407, Los Angeles, CA 90086-0407

4.Once a report has been filed: ALL restitution payments must be coordinated by the District Attorney’s Office. Should the check writer contact you to make payment, direct them to the Bad Check Restitution Program at (800) 269-0206.


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How to prepare bad check complaint form los angeles step 1

2. Once the last part is complete, you should add the required particulars in Check Writer, Information, Check Writers Name Address Apt, Drivers License Other ID State, Courtesy Notice must be sent to, Can the check, e r e h, k c e h c e t u t i t s b u s d e, i g i r o, e l p a t S, Step, Check, Information, Step, and Victim so you can progress to the next part.

e l p a t S, Check, and Information of bad check complaint form los angeles

3. The following segment is focused on Date Dear Check Writer You are, Bad Check Program Information, As a victim of a bad check you may, The following types of checks are, Twoparty checks Payroll credit, Partially repaid checks Postpre, and Fraudulent or stamped - fill in each one of these blank fields.

bad check complaint form los angeles writing process clarified (stage 3)

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