$---------. ---------, ---------, 19-.

Take notice, that a ---------, dated -------, 19-, for --------- dollars, drawn by --------- on ---------, payable --------- to the order of --------- at --------- and endorsed by you, was this evening at the request of --------- protested for nonpayment (or non-acceptance), the same having been presented and payment (or acceptance) demanded, which was refused.

The holder thereof looks to you for payment. ---------,

To ---------. Notary Public.

----------,----------.

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