"State of West Virginia
County of ....................., to wit:
......................................, upon oath complains that:
........................ 20 .... No...........
..............................................
(Name of Bank)
Pay to the Order of ..................... $.......... Dollars
For......................................................... when the maker did not have funds on deposit in or credit with this bank with which to pay the check, draft or order upon presentation against the peace and dignity of the State of West Virginia. The complainant therefore prays a warrant issue and that the maker be apprehended and held to answer the warrant and dealt with in relation thereto according to the law.
That since the time the check, draft or order was delivered the complainant has ascertained to the best of his or her knowledge and belief the following facts concerning the maker:
Full name .......................................................
Home address ....................................................
Home phone no............... Business phone no...................
Place of employment .............................................
Race ............ Sex .............. Height .....................
Date of birth ...................................................
DayMonthYear
..................................., Complainant
.................................................
AddressPhone No.
Taken, subscribed and sworn to before me, this .............. day of ......................, 20.....
.............................................
.............................................
(Title)
My commission expires the ........ day of .................., 20....."
W. Va. Code § 61-3-39f