Bounced cheque | Dishonoured cheque | Refer to Drawer Cheques

BOUNCED CHEQUE INSTRUCTION FORM

Bounced Cheque Instruction Form

If you have received a cheque that has been dishonoured for the whole or part of the debt it will assist your case immensely if you photocopy the front and back of the cheque(s).

If the bounced cheque does not represent the whole of the debt you must indicate to us which invoices the cheque was intended to discharge. Under no circumstances should you ever send the original cheque to us, only a photocopy and be sure to photocopy the back of the cheque as there is information on the back of the cheque that we require. This can be sent to us by Email or Post.

All fields marked with * are required

Your Name or Company’s Name:*

Contact person (if Company):

Address:*

City/Town:*

County:

Post Code:*

Tel:*

Mobile:*

Email:*

Amount of Cheque:*

The Bank you presented the cheque to:*

Details of Debtor

Name of Debtor (person or company that issued the bounced cheque):*

Address:*

City/Town:*

County:

Post Code:*

The date of presentation of your cheque(s) at your bank.*

(DD/MM/YYYY)

Was the cheque dishonored?*

	Returned by the Bank as “Refer to Drawer”
	Stopped (also known as Countermanded)

Was an invoice issued in respect of the debt? If yes, please state date of invoice:

(DD/MM/YYYY)