True Name without prejudice c/o Your Address City [zip] state, non-domestic To: Notary Name Address City, ST zip RE: Dishonor of NAME dba MANAGER and CREDITOR NAME (hereinafter collectively referred to as RESPONDENT) AFFIDAVIT AND REQUEST I, True Name, the undersigned Affiant, being of majority in age, competent to testify, a free woman (male/female) upon the land, affirm that the truths and facts herein are of first-hand personal knowledge, true, correct, complete, certain and not misleading, do hereby affirm and attest under penalty of perjury that: 1. Affiant tendered Bill of Exchange in settlement for all amounts due to RESPONDENT Payment Services Department via Certified Mail #0001 0000 0000 0000 0000 Return Receipt Requested on date, which was received and signed for on date; Affiant sent a letter to RESPONDENT requesting status on the settlement of Affiant‟s account on date via Certified Mail #7001 Return Receipt Requested, which was received and signed for on date; Affiant‟s Creditor April 2003 periodic statement did not reflect a credit to the account and a late fee was assessed; As of date, Affiant has received no other written response from RESPONDENT regarding Affiant‟s tender; Affiant‟s tender has been dishonored and not returned to Affiant. Date
3. 4. 5.
Affiant hereby requests you formally Protest RESPONDENT‟s dishonor of my presentment (a copy attached hereto) in accordance with The Notary’s Manual, Ninth Edition, §155:
“Another of the duties of notaries public is, „When requested, to demand acceptance and payment of foreign, domestic and inland bill or promissory notes, and protest the same for nonacceptance and nonpayment (See Duties, sec. 5, Sub, 1 supra)…‟ “While the term „protest‟ is the name of the formal instrument drawn up and signed by a notary public alleging the due presentment and dishonor of a bill or note and showing that the regular legal steps have been taken to fix the liability, as generally used the term includes all steps necessary to protect the holder against loss and fix the liability of the drawer and indorsers. These steps are presentment of the instrument to the proper parties and demand for acceptance or payment, as the case may be, and in case of refusal the giving of due and legal notice of dishonor and the noting and drawing up of the instrument of protest – the main purposes of the protest being to furnish the legal holder
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with evidence of presentment, demand, and notice of dishonor to be used in actions against the drawer and indorsers...” p. 124
and UCC 3-505 and RCW §62A.3-505:
(a) The following are admissible as evidence and create a presumption of dishonor and of any notice of dishonor state: 1. a document regular in form as provided in subsection (b) which purports to be a protest; 2. a purported stamp or writing of the drawee, payor bank, or presenting bank on or accompanying the instrument stating that acceptance or payment has been refused unless reasons for refusal are stated and the reasons are not consistent with dishonor; 3. a book or record of the drawee, payor bank, or collecting bank, kept in the usual course of business which shows dishonor, even if there is no evidence of who made the entry. (b) A protest is a certificate of dishonor made by a United States consul or vice consul, or a notary public or other person authorized to administer oaths by the laws of the place where the dishonor occurs. It may be made upon information satisfactory to that person. The protest must identify the instrument and certify either that the presentment has been made or, if not made, the reason why it was not made, and that the instrument has been dishonored by nonacceptance or nonpayment. The protest may also certify that notice of dishonor has been given to some or all parties .
IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my signature this ___ day of __________________ 2003.
Using a notary on this document does not constitute any adhesion, nor does it alter My status in any manner. The purpose for notary is verification and identification only and not for entrance into any foreign jurisdiction . _______________________ county ) ) ss. __________________ state Republic )
On this _____ day of _________________, 2003, before me, ____________________________, a Notary Public in and for the above state and county, personally appeared John Quincy Doe and Jane Sue Doe, who proved to me on the basis of satisfactory evidence to be the persons who attested and subscribed to the within instrument, by the above-named parties‟ unlimited commercial liability, as true, correct, complete and not misleading. Witness my hand and seal this ____ day of _____________ 2003, at _____________________________.
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