"STATE OF_______________
COUNTY OF_______________
_______________ , being first duly sworn on oath, deposes and states that he/she is at least eighteen (18) years of age and that on (date)_______________ , 2_______________ , he/she served the attached Notice of Dishonor by placing a true and correct copy thereof securely enclosed in an envelope addressed as follows:
_______________
_______________
_______________
and deposited the same, postage prepaid, in the United States mail at______________________________ .
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Subscribed to and sworn before me, this the_______________day of_______________ , 2 _______________ .
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My commission expires:
(signature)
(Notary Public)