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IN THE MAGISTRATE COURT OF WALTON COUNTY, STATE OF GEORGIA ond Drive Suite 116 303 South Hamm Monroe, Georgia 30655 [PHONE REDACTED] APPLICATION FOR DEPOSIT ACCOUNT FRAUD WARRANT Warrant Number (Affiant) (Defendant) VS. Business name (if applicable) (Address) (Address) (City, State, Zip Code) (City, State, Zip Code) (Area Code) Phone Number (Area Code) Phone Number I, do hereby make application for a warrant against the above named Defendant. (Affiant) Was the check received at the same time goods or services were received? YES NO Was the check presented to the bank within (30) days of receipt by payee? YES NO Has demand for payment been made by registered mail within (90) days of the date check received? YES NO Was the registered letter returned to you unclaimed? YES NO Has the (10) day period passed? YES NO Have any partial payments been made on this check? YES NO Has the Defendant given you a bad check prior to this? YES NO (if yes, when/where) Check written for: Rent Wages Service(s) Child Support State Taxes Merchandise (describe) Other Check returned for: Insufficient Funds (NSF) Account Closed No Account Other Location/Address check INFORMATION ON CHECK Name on account Address/Phone number Bank name listed on check Account Number: Date check was received Check Number Amount of check: Payable to Signature on check Endorsed by IDENTIFICATION OF DEFENDANT Driver’s License or Social Security Number obtained at the time check was received? YES NO (if yes, number) Date of birth obtained at the time check was received? YES NO (if yes, DOB) If other forms of identification provided by Defendant at the time the check was received by payee, explain Name of person/employee who cashed check (include address, phone number) I understand that I should not accept payment for this check after this warrant has been issued. Any future payment should be made directly to the Court. I understand that should I choose to withdraw this warrant after it has been issued, I will be responsible for the court costs in the amount of $63.50. I do solemnly swear/affirm that ALL information contained in this application for the criminal warrant of Deposit Account Fraud against the above named Defendant is true and correct. (Affiant) (Date) USE Sworn to and subscribe before me this Warrant APPROVED Warrant DENIED day of Felony Misdemeanor (Attesting Official) (Judge, Magistrate Court of Walton County)