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Notice of Dishonor of Note
Please take notice that a note, made by [name], for the sum of
---------- dollars ($----------), of [date], payable [number]
days after date to [name] and indorsed by you, has been presented
by me, at the request of Holder thereof, to [name] at [address]
in [state], and that payment being duly demanded, was refused,
whereupon, by directions of such Holder, the same has been
protested by me, and payment thereof is hereby requested of you.
*** If Required By State Law ***
This Section for Notary:
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.
My commission expires: _____