______________________________________ _____________________________________ NAME DATE ______________________________________ ADDRESS ______________________________________ CITY STATE ZIP NOTICE AND DEMAND “You are hereby notified that a check or instrument number ______________________ issued by you on _____________________ (date), drawn upon ____________________________ (name of bank), and made payable to , has been dishonored. Pursuant to Georgia law, you have ten days from receipt of this notice to tender payment of the full amount of the check or instrument plus a service charge of $30.00 or five percent (5%) of the face amount of the check or instrument, whichever is greater, the total amount due being $ _____________________. Unless this amount is paid in full within the ten day period, the holder of the check or instrument may file a civil suit against you for two times the amount of the check or instrument, but in no case more than $500.00, in addition to the payment of the check or instrument, plus any court costs incurred by the payee taking the action.” ______________________________________________ SIGNATURE ______________________________________________ NAME OF BUSINESS ______________________________________________ ADDRESS ______________________________________________ CITY STATE ZIP ______________________________________________ TELEPHONE American LegalNet, Inc. www.USCourtForms.com