STATE OF GEORGIA
COUNTY OF GWINNETT
) ) ) ) SS ) )
NOTARY CERTIFICATE OF DISHONOR AND NON-RESPONSE
PRESENTMENT Be it known, that a duly empowered Notary Public, in and for the STATE OF GEORGIA, COUNTY OF GWINNETT, a third party and not a party to the matter, at the request of BORROWER, Secured Party, did present on DATE, a Request for Debt Validation Pursuant to the FAIR Debt Collection Practices Act listed within Notary Certificate of Service via First Class Mail to: Bank CEO Address City, ST ZIP CODE hereinafter referred to as “Respondent,” signed by BORROWER, requesting Validation of Debt in re Account No. 0000, the time limit having elapsed for acceptance thereof and providing the requesting the requested validation and information, information, which was refused. PROTEST Whereupon, Whereupon, the Notary Public signing below, for the purpose and reason of Dishonor and NonResponse does publicly and solemnly certify the dishonor as against all parties it may concern for liability equivalent to three times the face value of the instrument and the claim of the debt, and all costs, damages and interest incurred, or hereafter incurred, by reason of nonperformance thereof and stipulations therein. NOTICE The undersigned undersigned Notary Public, certifies that on the day of ,2012, this Notice of Dishonor was sent to Respondent by depositing said document in the United States Mail, Registered Mail No. RE 0000 US, with Return Receipt Requested. T E S T I M O N Y In testimony of the above, I have hereunto signed my name and attached my official seal of office.
Lavaris Hopkins, Notary Public P.O. BOX 797 SNELLVILLE, GA 30078
