PARISH OF GRANT
ME, the undersigned authority, personally came and
___________________________________, who did affirm and state:
That on or
_________________________, one ________________________________
issue a worthless check in the amount of $_____________ plus______________
made payable to _____________________________ and gave that
check to the said
in payment of merchandise delivered by the said merchant/business.
Said check was later returned to the above merchant/business
or Account Closed after being timely presented in due course.
then duly notified ______________________________ by formal
to make good on the check, but the individual has failed to
for the amount owed.
WHEREFORE, affiant prays that the accused be arrested
and dealt with according to law.
DONE AND SUBSCRIBED BEFORE ME, this ________ day of ___________,