This Statutory Notice Is Provided Pursuant to Act

This statutory notice is provided pursuant to Act. No. 80-200, S.317, Regular Session of the Legislature of Alabama of 1980. You are hereby notified that a check or instrument numbered __________, apparently issued by you on __________________

(date) drawn upon the________________________________________(bank), has been dishonored.

Pursuant to Alabama Law, you have ten (10) days from receipt of this notice to tender payment of the full amount of such check or instrument plus a service charge of $____________, the total amount being $______________. Unless this amount is paid in FULL within the specified time above, the holder of such check or instrument may assume that you delivered the instrument with the intent to defraud and may turn over the dishonored instrument and all other information relating to this incident to the proper authorities for criminal prosecution.

FIRM_________________________________

ADDRESS_____________________________

______________________________________

TELEPHONE___________________________

BY____________________________________