City: State:--None--Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Check Information

Check Was Received In What County?: --None-- Chesterfield Darlington Dillon Marlboro Check Accepted Date (Can Be Different Than Check Date): Check Deposit Date (First Deposit Date Only): Was The Check Deposited Within 10 Business Days?: --None-- Yes No Was The Check Believed To Be Good At The Time Of Receipt?: --None-- Yes No Was The Check Postdated (Written For A Future Date)?: --None-- Yes No Was There Any Agreement To Hold The Check?: --None-- Yes No

The following section must be completed with the victim information.

Name: Company: Mailing Address: City / State / Zipcode:

Please Read

I could be held liable for the $91 in fees outlined in the S.C. Code of Laws Section 17-22-710 if I:

• Withdraw the check from the program
• Stop the prosecution process
• Accept full or partial payment on this check which could result in the collection or prosecution process being stopped

Confirm the following statements by selecting each box:

Signature (Typed):