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2. Date
   Date
4. From:
   Please state from whom this letter is from.
6. Address of Sender
8. City
9. State
10. Zip
12. You are hearby notified that your bank has dishonored a check issued by you and described below. Pursuant to Georgia law, you have ten (10) days from receipt of this notice to tender payment of the full amount of the check plus any and all service charges due per check. Unless the total amount due is not paid in full within the specified time above, the holder of the check or instrument may turn over the dishonored check or instrument and all other available information related to this incident to the Probate/Magistrate Court for the issuance of a criminal warrant or citation or to the district attorney or solicitor for criminal prosecution.
14. Name
    Prosecutor
16. First Name
17. Last Name
19. Address1
21. City
22. State
23. Zip
25. Bank Name:
26. Check # :
27. Date of Check
28. Amount of Check:
30. Service Charge Due:
31. Total Amount Due:
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

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