Notice of Dishonor of Draft

STATE OF ----------)

) s.s.:

COUNTY OF ---------)

[date]

Please take notice that a draft for ---------- dollars ($----------), drawn by [name] on [institution], in favor of [name], or order of [date], and payable on [date], [acceptance or payment] of the draft was this day demanded, and not having been [accepted or paid] was PROTESTED by the undersigned Notary Public for [nonacceptance or nonpayment]. Holder looks to you for payment as [drawer or indorser].

[signature]

*** If Required By State Law ***

This Section for Notary:

ACKNOWLEDGMENT

State of _________

County of ________ [COUNTY]

On [DATE] before me, [NAME OF NOTARY], notary, personally appeared [NAME OF PERSON(S) INVOLVED], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

Witness my hand and official seal.

Signature ________
Notary

My commission expires: _____

(Seal)