Darrin C. Devinney
County Attorney
Assistant County Attorneys
Cheryl Pierce
Brett Sweeney
Assistant County Attorneys
Amber Norris
Alice Burns
Joseph Penney
BUTLER COUNTY, KANSAS
OFFICE OF THE COUNTY ATTORNEY
201 W. Pine, Suite 104, El Dorado, KS 67042
Facsimile (316) 321-4120
Telephone (316) 321-6999
(800) 822-6374
Worthless Check Guidelines
Attached is an Offense Report and Affidavit for you to copy and to use in the future.
Please be aware that as July 1, 2012 the Butler County Attorney's policies on accepting
worthless checks are the following:
1.
2.
3.
4.
5.
6.
7.
8.
No checks will be accepted over 90 days old.
No checks will be accepted for less than $100.00.
Use only one report for each check.
The person who accepted the check must sign the report.
All questions must be answered. If you do not know the answer please write "unknown
or N/A if they do not apply.
Birth date and/or driver’s license number is required and must be written on the check.
Offense Report and Affidavit must be signed and completed and Affidavit notarized.
Must be able to identify the check passer and/or a video of the transaction must be
submitted with the check.
If you are unable to submit the required information you may pursue the worthless checks by
contacting the Clerk of the District Court, Small Claims Department as a civil matter. We ask
that you do not submit a check to our office for prosecution without the information as stated
above as our office does not collect worthless checks, but we do prosecute worthless checks.
Please forward all future checks with the proper guidelines so that we may prosecute these
matters more efficiently.
Please return Offense Report, Affidavit, check and certified letter receipt to the County
Attorney’s Office. If you have further questions, please contact this office.
Sincerely,
Cathy Lowmaster, Legal Assistant for
Amber R. Norris
Assistant Butler County Attorney
OFFENSE REPORT FOR WORTHLESS CHECKS
INSTRUCTIONS: All questions in this report must be answered completely. Please print all
answers. Use only one report for each check.
Please do not guess any answers. If you do not know the answers, write "unknown". If the
questions asked do not apply to your situation, please write "N/A".
All witnesses must sign the report. Please provide contact information for all witnesses.
When the report is completed, it must be returned to the Butler County Attorney's Office,
201 W. Pine, Suite 104, El Dorado, KS 67042. If you have any questions, please contact our
office at (316) 321-6999.
SECTION 1.
1. The check passer. (This section is to be completed by the person receiving the check)
2. Sex:
7. Eyes:
3. Age:
8. Scars, tattoos or other identifying marks/piercings:
4. Race:
9. Height:
5. Birth Date:
10. Driver’s License #:
6. Hair:
11.
a. Name of person receiving check:
b. Can they identify the check passer?
12. Have you seen check passer before the date he/she passed this check?
Yes
No
13. Name of anyone else present at the time the check was passed.
(Who can identify the passer?)
14. Is the passer the same person who signed it? Yes
15. If not, what is the address of the check passer?
No
WE AGREE WE WILL APPEAR AND TESTIFY TO THE ABOVE INFORMATION IN A COURT OF LAW
FOR THE PURPOSE OF PROSECUTION.
____________________________________________________________________
Signature of person receiving the check – address and phone – date
____________________________________________________________________
Signature of witness to passing the check – address and phone – date
SECTION 2. The check writer (Complete this section ONLY IF the check passer is not the person
whose signature appears on the check.) This section may be completed by any witness who can
answer these questions.
Name of check writer:
Can you identify the check writer?
Yes
No
Have you done business with the check writer before?
Yes
Was the check writer present when the check was passed?
No
Yes
No
What part of the check did the check writer and check passer write?
__________
SECTION 3. The check transaction (This section should be completed by the person receiving
the check.)
1. Date on the check:
2. Check number on check
3. Date check received:
4. Name of Victim:
_______________________________________
5. Victim’s address:
6. Victim's phone number:
Alternate phone:
7. Address where check was passed:
8. Check was passed
in person
by mail
9. Purpose for which check was given:
10. Where did the check passer receive the goods or services:
11. When did check passer receive the goods or services:
12. Has the merchandise or services been returned:
13. If yes, date:
Yes
No
location:
reason:
14. At the time the check was passed were statements made to the effect he/she did not
have enough money in the bank to cover the check:
Yes
No
15. At the time the check was passed did the check passer ask you to hold the check or
delay depositing it:
Yes
No
16. Did you or any other employee or supervisor agree to hold the check or delay depositing
it:
Yes
No
17. Did you accept the check in good faith believing that there was enough money on
deposit at the time to allow the check to clear the bank:
18. Reason check was returned by bank:
Account Closed
Yes
No
NSF
Other
SECTION 4. Contact with the check writer/passer after transaction. (This section is to be
completed by employer or the person who attempted to collect on the check)
Prior to receiving this check have you or your firm received any checks from this person or on
this account which were worthless:
Yes
No If yes, when and how
many?_________________
If so, what happened on these earlier checks:
Name of person who sent 7 day letter to the check writer/passer:
Name of person who mailed 7 day letter:
If letter was sent to address different than address on check, explain why:
If check writer has been notified in any other way that the check was returned, who told
him/her:
Date of notification:
Manner:_______
What agreements, if any, were made about the restitution on the returned check:
What payment, if any, was paid or offered towards restitution on this check:
_______
Has any payment towards restitution been received:
Yes
No
WE AGREE WE WILL APPEAR AND TESTIFY TO THE ABOVE INFORMATION IN A COURT OF LAW
FOR THE PURPOSE OF PROSECUTION. WE FURTHER AGREE NOT TO ACCEPT RESTITUTION NOR
ATTEMPT TO BARGAIN WITH THE CHECK WRITER/PASSER OR ANYONE ELSE ON HIS/HER BEHALF
ABOUT THIS CHECK WITHOUT PRIOR APPROVAL OF THE COUNTY ATTORNEY.
Signature of person writing 7 day letter- address and phone- date
Signature of person mailing 7 day letter- address and phone- date
Signature of other person contacting check passer/writer address and phone – date
AFFIDAVIT
STATE OF KANSAS,
COUNTY OF BUTLER
Comes now the undersigned, of lawful age and being first sworn upon his/her oath and
alleges as follows:
The attached check was given to
on the
day of
, 20___, by a person identified as _________________________
who in return received goods/ wares/ merchandise/ cash for said check and said check was not
given for a pre-existing debt. The check was personally received by
_____________________________ from the passer
_______________________________.
1. At the time the check was made, uttered, and passed, the maker or passer did not
indicate by words or action that he/she had no deposit in or credits with said bank
or that he/she did have sufficient funds in or credits with said bank for the payment
of the check.
2. That we were not requested to hold the check.
3. The maker or passer of said check did not borrow any money and give the check as
security for a debt of loan.
4. The check was not post-dated.
5. The check was submitted from the bank marked _____________________________,
we did on the ______ day of ____________, 20___, by letter deposited as restricted matter in
the U.S. Mail, addressed to the addressee only at the address as it appears on said check, draft,
or order advising the maker of the failure of the check to clear the bank and warned that if the
check was not paid within seven (7) days, it would be submitted for prosecution. We also
notified the maker or passer of the check by the following means: ______________________.
The attached check is submitted to the Butler County Attorney’s Office for the purpose
of prosecution with the full understanding that the prosecution will not be dismissed because
restitution has been made. I further understand that upon delivery of the check to the Butler
County Attorney's Office, restitution cannot be accepted by me, but should be directed to the
Butler County Attorney.
I am aware that under the provision of K.S.A. 21-5822, causing the unlawful prosecution
for worthless check is a Class A Misdemeanor, punishable by not more than one (1) year in the
County jail and/or a fine not to exceed $2,500.00, and the cost of the unlawful prosecution.
Causing an unlawful prosecution for worthless checks is filing this affidavit on a check that has
sufficient funds to pay said check, draft, or order upon presentation at the bank or depository.
Having read the foregoing, I do hereby affix my signature this _______ day of
______________, 20___.
Signature of Affiant
Business Address
Business Phone
Home Phone
Subscribed and sworn to before me on this _______ day of _________
, 20_____.
NOTARY PUBLIC
My Term Expires: _______________________