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APPLICATION FOR A CRIMINAL BAD CHECK ARREST WARRANT (PLEASE TYPE OR PRINT WITH BLACK OR BLUE INK) Liberty County Magistrate Court 201 South Main Street, Suite 2100 Hinesville, Georgia 31313 (912) 368-2063 WARRANT ( M / F ) (FOR OFFICE USE ONLY) I, Name of Affiant Business Name Address Zip Code Telephone do hereby file this application for a warrant for: Name (Person signing check) Address Telephone Name (Person presenting check) Address Telephone Date check was given to Complete address where check was Was the check given for (check options that apply): Merchandise Cash Rent Service Child Support State Taxes Other---- What Was the check given at the same time goods or services were Was the check presented to the bank within 30 days of receipt by Check was returned for: Insufficient Funds Account Closed No Account Stop Payment Has demand for payment been made by registered mail? Yes No Was the registered letter returned to you unclaimed? Yes No Has the ten (10) day period passed? Yes No Have any partial payments been made on this check? Yes No Was this check post-dated or held for any amount of time? Yes No Has defendant given a bad check before? Yes No Where and INFORMATION ON CHECK Name, phone number and address of person physically taking Check written on what On account Payable Check Signed Account Endorsed COMPLETE OTHER SIDE ---PAGE BREAK--- OFFENDERS INFORMATION Drivers License No. & Date of S.S. WITNESSES (persons present when check was signed): ADDITIONAL I understand that after I apply for this warrant and do not prosecute, I will be charged up to $125.00 court costs. I do solemnly swear (or affirm) that ALL of the information contained in this application for a criminal warrant is true and correct. Your Signature Date Sworn to and subscribed before me Judge/Clerk Magistrate Court Upon full restitution and payment of court costs, I recommend the warrant against the above defendant be dismissed. Your Signature FOR OFFICE USE ONLY WARRANT ISSUED WARRANT DENIED (Rev. 2\16\17)