Complaint against Cheque Dishonour - A Sample Form

This is a form of Complaint against Cheque dishonour. A PDF version of the format can be downloaded from the link given below for Free.



Complaint Case No.  _____ of  ____

Police Station:______

(Name & full particulars)

                            .... Complainant/Petitioner.

(Name & full particulars)


Charge under section 138 read with section 142 of the Negotiable Instruments Act, 1881 as amended up-to-date.

The   humble   petition   of
complaint on behalf of the 
complainant   above named


1.    The complainant/petitioner is a law abiding citizen of India and ________ by profession.

2.    Sometime in the month of _____________ the accused person requested the complainant to provide him some financial help as an interest-free loan to the tune of Rs. ________/- (Rupees __________) only to fulfill his urgent necessity and promised to repay the said amount within three months.

3.    Upon the request made by and believing in the promise of the accused the complainant provided him such loan/financial accommodation of Rs. ______/- (Rupees ___________________) only.

4.    In discharge of the existing legal debts and/or liabilities as aforesaid one A/c payee cheque was issued by the accused in favour of the complainant.

A detail of the said cheque is given below:-

Cheque No.    Date     Drawn on        Amount (Rs.)

………….    ……….  ...................    ………….

5.    Upon presentation of the said cheque for encashment within its validity period with the complainant’s banker, __________________, the same was dishonoured and returned unpaid alongwith the Cheque Returning Memo dated ___________ with the endorsement “Insufficiency of funds in the account”. The Compalinant was intimated about such dishonour by Debit Advice Memo dated ___________.

6.    The fact of such dishonour of the cheque had been communicated to the accused person by a notice U/s. 138(b) of N.I. Act, 1881 as amended upto-date issued by the Complainant and the said notice was despatched by Regd. Post with A/D on __________ demanding the payment of the amount of the said cheque i.e. Rs. _______/- (Rupees _____________) only within 15 days from the date of receipt of the said notice.

7.    The Complainant submits that the said demand notice was duly duly received by the accused person on ________,  but inspite of this the accused person failed and neglected to make payment as demanded therein.

8.    The accused person has therefore succeeded in deceiving the complainant malafidely, intentionally, purposely and mischieviously.

9.    The accused has thus committed an offence punishable under section 138 of the Negotiable Instruments Act, 1881 as amended upto-date.

10.    This petition of complaint is not barred by the Law of Limitation.

11.    The cause of action of this case arose within the jurisdiction of this Learned Court. Hence, this Learned Court is the competent authority and has jurisdiction to try the offence in this instant case.

12.    This petition of Complaint is made bonafide and for the ends of justice.


In the aforesaid circumstances it is most respectfully prayed that Your Honour may graciously be pleased to take cognizance of the matter and issue process against the accused person under section 138 read with section 142 of the Negotiable Instruments Act 1881, as amended up-to-date and pass such other order or orders as your Honour may deem fit and proper.

And for this act of kindness your petitioner as in duty bound shall ever pray.

List of Documents annexed:-

1.    The aforesaid cheque No. _____ in original,

2.    The Cheque Returning Memo. Dated _________ in original,

3.    The Debit Advice Memo. Dated _____ in original,

4.    True copy of the Notice dated ________,

5.    Postal Receipt No. ________ in original,

6.    A/D card having endorsement by the accused, in original.

List of Witness:-

1.    Complainant,

2.    Representative from ________ Bank, _______ Branch,

3.    Representative from _______ Bank,

4.    Others.

Place: ________

Date: ________

Filed By,





I, ___________ (Name), son of ____________, aged about ________ years and resident of __________do hereby solemnly affirm and declare on oath as follows:

1.    That I am the Complainant in the Complaint annexed herewith and as such competent to swear this Affidavit.

2.    That the statements made in the paragraphs nos. 1 to 12 of the said Complaint are true to the best of my knowledge and belief and the rests are my humble prayer to the Learned Court. I have not also concealed anything therein.

I sign this affidavit on this ______ day of _______, 20__ at _________.



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1 comment:

  1. I hope every one will across such type of issue so these are very useful to all.We can just follow the format and we can just copy and fill the form for our use.

    Free sample forms


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