GENERAL SESSIONS COURT OF __________________________________ COUNTY TENNESSEE
	
	State of Tennessee vs. _________________________________________________________________________________________

	State Control # __________________________________  ____________________________ County Case # ____________________

Attorney for Defendant_______________________________	Address _________________________________________________

Court Date _________________________________________		 __________________________________________________
State, Deft. to _______________________ at ________ am/pm		Phone ______________________DL# ___________________
State, Deft. to _______________________ at ________ am/pm		DOB _______________________SSN# __________________
State, Deft. to _______________________ at ________ am/pm		Sex ____ Race ____ Ht ____ Wt ____ Hair ____ Eyes ______
State, Deft. to _______________________ at ________ am/pm		Work ______________________________________________
	
AFFIDAVIT OF COMPLAINT
WORTHLESS CHECK/SIGHT ORDER – T.C.A. § 39-14-121

The undersigned affiant, after being duly sworn according to the law, states that the Defendant, whose name is otherwise unknown to the affiant, committed the offense of issuing or passing a worthless check, a violation of T.C.A. § 39-14-121, in _________________ County on or about ________________, for the amount of $____________ and service charge of $___________.
	Further, affiant makes oath that the essential facts constituting said offense, the source of the affiant’s information, and the reasons why his/her information is believable concerning said facts are as follows:  ٱ personal knowledge; or ٱ that he/she has received information from __________________, whom he knows to be a reliable and credible informant because said informant had previously given him information of a similar nature which subsequently had been verified and/or that said informant had been an employee in good standing of ________________ for ________ years and _____ months, and that said informant told said affiant that the defendant knowingly or with fraudulent intent

	issued or passed a check or similar sight order for the payment of money for the purpose of paying any fee, fine, tax, license or obligation to any governmental entity or for the purpose of obtaining money, services, labor, credit or any article of value, knowing at the time there were not sufficient funds in or on deposit with the bank or other drawee for the payment in full of the check or order, as well as all other checks or orders outstanding at the time of issuance; or

	stopped payment on a check or similar sight order for the payment of money for the purpose of paying any fine, fee, tax, license or obligation to any governmental entity or for the purpose of obtaining money, services, labor, credit or any article of value; provided, that such money, credit, goods or services were as represented at the time of the issuance of the check or similar sight order;

AND
	the defendant did not have an account with the bank or other drawee at the time the defendant issued or passed the check or similar sight order; or  

	on presentation within thirty (30) days after issuing or passing the check or similar sight order, payment was refused by the bank or other drawee for lack of funds, insufficient funds or account closed after issuing or passing the check or order, and the defendant failed to make good within ten (10) days after receiving written notice of that refusal if such notice was required.  It can be inferred that the defendant received the notice no later than five (5) days after it was mailed if the notice was sent by certified mail with return receipt requested to the defendant at the address shown:  ٱ on the check or similar sight order; or ٱ on the records of the bank or other drawee.  

Affiant’s Signature:  ________________________________	Sworn to and subscribed before m me on

Name (Printed):  ___________________________________	________________________________________, 20 ____

Address (Printed):  _________________________________	________________________________________________
	Judge/Clerk/Judicial Commissioner
_________________________________________________

Phone Number:  ____________________________________

PROBABLE CAUSE DETERMINATION 

	Based on the affidavit of complaint, I find there is probable cause to believe that on the date set forth above in  ___________ County Tennessee the defendant committed the offense(s) of violation(s) of TCA § _____________________________________________
_______________________________________________________________________________________________________________________

(  ) Defendant given citation or arrested without warrant	(  ) Arrest warrant shall issue	(  ) Criminal summons shall issue

Date _______________________________________		__________________________________________________
			Judge/Clerk/Judicial Commissioner