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Notice Of Dishonor Of Note

(Type B)

"Without Prejudice"

Date

To: [name]

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.

Signature

[Name], of Note Maker

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)