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Back to Forms for 'Debtor and Creditor'.





To:  ______________________ (party liable on instrument)

       ______________________ (address)




Please take notice that a __________ (draft) drawn by __________ (drawee), of __________ (address), __________ (city), __________ County, __________ (state), on __________ (drawee), of __________ (address), __________ (city), __________ County, __________ (state), to pay __________________ Dollars ($__________) on __________ (date), to __________ (payee), of __________ (address), __________ (city), __________ County, __________ (state), was presented by __________, the undersigned, of __________ (address), __________ (city), ______________ County, __________ (state), who is the present holder of the ___________________ (draft), to __________ (drawee) for acceptance on __________ (date), at __________ (address), __________ (city), __________ County, __________ (state), at __________ (time). __________ (Drawee) refused to accept the _______________ (draft). Therefore, the undersigned looks to you for payment, including all interests, costs, and charges that have already accrued or that may accrue in the future by reason of the nonacceptance of this __________ (draft).



Dated: _____________________





(Signature of Holder)


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