Fill and Sign the Check Bad Form

NOTICE OF DISHONORED CHECK Date: ___________________________ To:                               You are hereby notified that a check numbered ___________ in the face amount of $ ___________ issued by you on (date) ______________________ , 20 ___ , drawn upon (name of bank) ___________________________ , and payable to ___________________________ , has been dishonored. Pursuant to Florida law, you have 7 days from receipt of this notice to tender payment in cash of the full amount of the check plus a service charge of $25 if the face value does not exceed $50; $30 if the face value exceeds $50 but does not exceed $300; $40 if the face value exceeds $300, or 5 percent of the face amount of the check, whichever is greater, the total amount due being $ ___________ . Unless this amount is paid in full within the time specified above, the holder of such check may turn over the dishonored check and all other available information relating to this incident to the state attorney for criminal prosecution. You may be additionally liable in a civil action for triple the amount of the check, but in no case less than $50, together with the amount of the check, a service charge, court costs, reasonable attorney fees, and incurred bank fees, as provided in s. 68.065. Mail or deliver the total amount to the following:                               Notice Issued by: Signature: ________________________________ Print Name: _______________________ Title: _______________________