(Copy of bill or note protested)

United States of America,

State of ---------, --------



Be it known by this Instrument of Protest: That at the close of banking hours, on ---------the ------- day of ---------, A. D. 19-, I ---------, a notary public within and for said County of ---------, did, at the request of ---------, holder of the original ---------hereto attached and copied above, present the same to --------at ---------in the City of ---------, ---------, and demanded payment (or acceptance) thereof, which was refused for the following assigned reason: ---------.

Whereupon I protested the same for non-payment (or non-acceptance) and notified the following-named drawer and indorser thereof of said presentment and protest, by a separate notice to each, enclosed in (the same, or, separate) envelope, and addressed as follows: ---------, and deposited the same in the post office of ---------in said County, the same day, postage paid; and the following-named drawer and indorser thereof, by delivering to each of them such notices personally on the same or the next day ---------.

Whereupon 1, the said notary, upon the authority aforesaid, have protested and do hereby solemnly protest as well against the drawer of the said --------as against all other persons whom it doth or may concern, for exchange, re-exchange, and all costs, charges, damages, and interest, suffered or to be suffered, for the want of payment (or acceptance) thereof, and I certify that I have no interest in the above-protested instrument.

Witness my hand and notarial seal this ---------day of ---------, 19-.

Protest Fees, $---------. ---------,

[Notarial seal.] Notary Public.