Bethel, Connecticut

Date: ______________
Mr.
Mrs.
Miss____________________________________

Address_________________________________

City _________________________________

Dear____________________________________

On ____________________, you issued to the undersigned a bad check in the amount of

$_________________________, dated the same day.

The purpose of this letter is to advise you that unless restitution is made to the undersigned within eight (8) days, the police department will be asked to obtain a warrant for your arrest on the charge of "Issuing a Bad Check".

Sincerely,

________________________
Name of Compalinant

________________________
Address


Date: __________________

I certify that the original of the above letter was mailed by (registered) (Certified) mail, return receipt requested, to the above named address on _____________, 20___, and that restitution has not been made. I request that said addressee be arrested for Issuing a bad check, and I will appear against him/her.

___________________________
Signature of Complainant