Affidavit Of Complaint Form - Tennessee
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1GENERAL 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: ٱpersonal knowledge; or ٱthat 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: ٱon the check or similar sight order; or ٱon 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
§ _____________________________________________
_______________________________________________________________________________________________________________________
Criminal summons shall issue
( ) Defendant given citation or arrested without warrant
( ) Arrest warrant shall issue
( )
Date _______________________________________
__________________________________________________
Judge/Clerk/Judicial Commissioner
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