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 endorser].

[signature]

Notary Public

To: [name]