Fifth Judicial Circuit Solicitor's Office, South Carolina
The State of South Carolina
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SOLICITOR’S OFFICE
Fifth Judicial Circuit
DIVERSION PROGRAMS & COMMUNITY SERVICES
Alcohol Education Program (AEP) ● Expungement ● Juvenile Court Alternative Program (JCAP) ●
Juvenile Pretrial Intervention (JPTI) ● Pretrial Intervention (PTI) ● Traffic Education Program (TEP) ● Worthless Check Program
WORTHLESS CHECK WORKSHEET
1. Check Writer’s Information:
Name: ___________________________________________________________________ SEX_____ RACE_____
Address: _____________________________________________________________________________________
City State Zip Code
Phone: _____________________________ ID or DL#: _____________________________ STATE: __________
DOB: ______________________________________ SSN: ___________________________________________
2. Date the check was accepted (Can be different than check date): ______________________________________________
3. Date check deposited (1st deposit date only): ______________________________________________________________
4. Bank where check was deposited: ______________________________________________________________________
5. Deposited within 10 days? YES NO
6. Check was received in Richland County? YES NO
7. Check was received in Kershaw County? YES NO
8. Did you or your agent believe that the check was good at the time of receipt? YES NO
9. Was the check postdated? YES NO
I understand that by signing this form that I attest that there was no agreement to hold the check in question. If I later decide to stop the collection or prosecution process, I will be liable for costs totaling at least $91ºº.
By signing this form, I swear that the above is true.
SIGNATURE: ____________________________________________________ DATE: _________________________________
PRINT NAME: __________________________________ COMPANY: ______________________________________________
ADDRESS: _______________________________________________________________________________________________
City State Zip Code
PHONE: ______________________ E-mail: ___________________________________________________________________
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Byron E. Gipson
Solicitor
April Sampson
Deputy Solicitor
Daniel R. Goldberg
Deputy Solicitor
Curtis A. Pauling III
Deputy Solicitor
Richland County
1701 Main Street, Suite 408
Columbia, SC 29201
Phone: (803) 576-1860
Fax: (803) 576-1629
Kershaw County
1121 Broad Street
Camden, SC 29020
Phone (803) 425-7672
Fax: (803) 425-6029
Mailing Address
PO Box 1238
Columbia, SC 29202
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