Affidavit of Having Given Notice of Dishonor -- by Mail

State of: ____________________

County of: __________________

I, ________________, of _______________________ (address), _______________ (city), _______________ (county), ___________________ (state), a notary public of ____________________ (state), duly commissioned and sworn, do hereby certify:

I am a citizen and resident of __________________ (city), ________________ (county), ____________________ (state); I am over the age of __________ years.

I am neither interested in nor a party to the matter referred to in the copy of the notice attached to this document.

On ____________ (date), I served notice of dishonor of the __________ (draft or note), which provides for payment to __________________ (payee), of _________________ (address), __________________ (city), _______________ (county), ______________ (state), of __________ Dollars ($__________) on ____________ (date), by __________________ (drawer or maker), of _________________________ (address), at ______________________ (address), __________________ (city), ____________ (county), _________________ (state), ____________________ (if draft, add drawn on _________________ (drawee),) by mailing the notice by ________________ (certified or registered) mail, with return receipt requested and postage fully prepaid. The notice of dishonor was mailed on ____________ (date), at ____________ (time) at the _______________ (post office or mailbox), located at ________________. The notice was sent to _______________ (party liable on instrument), of ____________________ (address), ________________ (city), ________________ (county), _______________ (state), which is __________ (his or her) reputed residence.

There was regular communication by United States mail between the place of mailing and the place of destination at the time of the mailing of the notice described above.

Dated: _____________________________

Signature: __________________________