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Fill and Sign the Willmar Police Department 2201 23 Street Ne Suite 102 Willmar Form

Fill and Sign the Willmar Police Department 2201 23 Street Ne Suite 102 Willmar Form

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NOTICE OF DISHONORED CHECK Date: ___________________________ To: [fill in name and address of offender] You are hereby notified that Check No. ___________, dated ___________ in the amount of $___________, drawn upon ___________ and payable to ___________ has been dishonored for the reason of ________________. Pursuant to Oklahoma State law (OS Title 21, Chapter 61, § 21-1541.4), you have five (5) days from receipt of this notice to tender payment of the total amount of the che ck(s) or instrument(s), plus the amount of any fees charged by any financial institution as a re sult of the checks being dishonored, the total amount due being $___________. Unless this amount is paid in full within the time specified above, the dishonored check(s) or instrument(s) and all ot her available information relating to this incident may be turned over to the prosecut ing attorney for criminal prosecution. Mail or deliver the total amount to the following: Notice Issued by: Signature: ________________________________ Print Name: _______________________ Title: _______________________

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