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Notice Of Dishonor Promissory Note

(Type A)

To: [Party Liable on Instrument]

[Address]

Please take notice that presentment of a promissory note for [$------] made by [Maker], of [Address], and payable to [Payee], of [Address], on [Date], was made on [Date]. The undersigned, who is the present holder of the promissory note described above, presented the note to [maker] and payment was demanded.

[Maker] refused to make payment. The undersigned, therefore, looks to you for payment, including the payment of all interest, costs, and charges that have already accrued or that may accrue in the future by reason of the nonpayment of this promissory note.

Dated:

Signature

[Name of Holder]

*** If Required By State Law ***

This Section for Notary:

Acknowledgment

STATE OF -------)

) ss: [Date]

COUNTY OF ------)

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]

[Name of Notary Public]

My commission expires: [date]

(Seal)