Fill and Sign the Notice Check Bad Form

NOTICE OF DISHONORED CHECK (seeking criminal penalties) Date: ___________________________ To:                               You are hereby notified that a check or instrument numbered: ___________ , apparently issued by you on ___________________________ [date], in the amount of $ ___________ , drawn upon ___________________________ [name of bank], and payable to ___________________________ , has been dishonored. Pursuant to Montana Code §45-6-316, you have five (5) days from receipt of this notice to tender payment of the total amount of the check or instrument, the total amount due being $ ___________ . Failure to pay the above amount within the period specified may also result in following penalties: A person convicted of issuing a bad check shall be fined not to exceed $1,000 or be imprisoned in the county jail for any term not to exceed 6 months, or both. If the offender has engaged in issuing bad checks that are part of a common scheme or if the value of any property, labor, or services obtained or attempted to be obtained exceeds $1,000, the offender shall be fined not to exceed $50,000 or be imprisoned in the state prison for any term not to exceed 10 years, or both. Montana Code § 45-6-316(3) . Make full payment to ___________________________ , at the following address: Mail or deliver the total amount to the following:                               Notice Issued by: Signature: ________________________________ Print Name: _______________________ Title: _______________________