Form C-812 (03/2019) AFFIDAVIT (BANK ERROR or FREEZE) 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 in the amount of , (Month/Day/Year) made payable to , drawn on the account of or endorsed by (Name of Permittee) , operator of , (Name of Representative) (Name of Retailer, Mixed Beverage, or Private Club Permittee) which was dishonored on the day of ,20 by this bank for insufficient funds (Month & Year) when presented for payment was the result of: Bank Error (Adequate funds were available) Account Frozen by IRS or State Comptroller. On the day when the above check was presented for payment, there was (sufficient / insufficient) funds on deposit to cover the transaction. (Circle one) Other: Bank Representative222s Signature (Notary Seal) Title Phone Number E-Mail Address SWORN TO AND SUBSCRIBED BEFORE ME, the undersigned authority, this the day of AD, . Notary Public in and for the State of Texas American LegalNet, Inc. www.FormsWorkFlow.com