_______________________________________ NAME ________________________________ DATE _______________________________________ ADDRESS _______________________________________ CITY STATE ZIP NOTICE AND DEMAND You are hereby notified that the following check(s) or instrument(s): CHECK NO. CHECK DATE CHECK AMOUNT NAME OF BANK Drawn upon ________________________________________________ (name of bank) and payable to ______________________________________, (has) (have) been dishonored. Pursuant to Georgia law, you have ten days from receipt of this notice to tender payment of the total amount of the check(s) or instrument(s) plus the applicable service charge(s) 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 specified time above, a presumption in law arises that you delivered the item(s) with the intent to defraud and the dishonored check(s) or instrument(s) and all other available information relating to this incident may be submitted to the Magistrate for issuance of a criminal citation or to the District Attorney or Solicitor General for criminal prosecution. ________________________________ NAME ________________________________ ADDRESS ________________________________ CITY STATE ZIP Revised 03/14/2008 American LegalNet, Inc. www.FormsWorkflow.com