Affidavit (Bank Error)
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Affidavit (Bank Error) Form. This is a Texas form and can be use in Alcoholic Beverage Commission Statewide.
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Tags: Affidavit (Bank Error), C-812, Texas Statewide, Alcoholic Beverage Commission
Form C-812 (9/2010)
AFFIDAVIT
(BANK ERROR)
STATE OF TEXAS
COUNTY OF_______________
BEFORE ME, the undersigned authority, this day personally appeared __________________________________,
who is a credible person, and who, after being by me duly sworn, did depose and say:
That I am an officer of ______________ located at ___________________________________.
(Name of Bank)
(Address)
This is to certify that Check Number _____________ dated _____________________
(Month/Day/Year)
in the amount _________________________ , made payable to __________________________
(Name of Permittee)
Drawn on the account of, or endorsed by ____________________ operator of ____________________________,
(Name of Representative)
(Name of Retailer, Mixed Beverage, or
Private Club Permittee)
which was dishonored on the ___________ day of _______________________
(Month/Year)
by this bank for insufficient funds when presented for payment was the result of an error by this bank.
On the __________day of ________________ when the above check was presented for payment, there were
(Month/Year)
adequate funds on deposit at that time.
______________________________
Bank Representative’s Signature
_________________________________
Address
(Notary Seal)
_________________________________
Phone Number
________________________________
Title
SWORN TO AND SUBSCRIBED BEFORE ME, the undersigned authority, this the _______________
day of _________________ AD,__________________________ .
___________________________________________
Notary Public in and for the State of Texas
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