Fill and Sign the Stopped Payment 497303796 Form

NOTICE OF DISHONORED CHECK Date: ___________________________ To:                               You are hereby notified that the following instrument(s): Check No. Check Date Check Amount Name of Bank ___________ ___________ $ ________________ ____________________________________ ___________ ___________ $ ________________ ____________________________________ ___________ ___________ $ ________________ ____________________________________ ___________ ___________ $ ________________ ____________________________________ ___________ ___________ $ ________________ ____________________________________ and payable to ____________________________________ , has/have been dishonored. Pursuant to Georgia law (§16-9-20), you have ten days from receipt of this notice to tender payment of the total amount of the instrument(s) plus the applicable service charge(s) of $ ___________ and any fee charged to the holder of the instrument(s) by a bank or financial institution as a result of the instrument(s) not being honored, 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 instrument(s) with the intent to defraud and the dishonored instrument(s) and all other available information relating to this incident may be submitted to the magistrate for the issuance of a criminal warrant or citation to the district attorney or solicitor- general for criminal prosecution. Mail or deliver the total amount to the following:                               Notice Issued by: Signature: ________________________________ Print Name: _______________________ Title: _______________________