Returned Check Notice - Template, Sample Form Online

________

FROM:

________
________

TO:

________
________

Sent via: ________ (Certified Mail, Return Receipt Requested, No. ________)

RE: Notice of Dishonored Check — Demand for Payment

Dear ________,

§ 1. Notice of Dishonor. This letter constitutes formal notice that a check you issued has been dishonored and returned unpaid. The particulars of the dishonored instrument are as follows:

1. Check Number: ________;
2. Date of Check: ________;
3. Drawer (Maker): ________;
4. Drawee Financial Institution: ________, located in ________;
5. Face Amount of Check: $________ (________);
6. Payee: ________;
7. Reason for Dishonor: ________ (e.g., insufficient funds, account closed, stop-payment, no account).

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§ 3. Statutory Demand. You are hereby notified and demanded, pursuant to the applicable bad-check and dishonored-instrument statutes of the State of ________ and Article 3 of the Uniform Commercial Code as enacted therein, to pay the full face amount of the dishonored check together with all permitted charges. Failure to make payment within the statutory period after receipt of this notice may subject you to additional civil liability, including statutory damages, service charges, costs of collection, and reasonable attorney's fees, and may further result in referral of this matter for criminal prosecution and/or civil action to the extent permitted by law.

§ 4. Itemization of Amounts Due. The amounts presently due are itemized as follows:

1. Face Amount of Dishonored Check: $________ (________);
2. Returned Check Service Fee: $________ (________);
3. Cost of Mailing This Notice: $________ (________);
4. Total Amount Now Due: $________ (________).

Any service charge or fee assessed above is imposed only to the extent permitted by applicable federal and state law and does not exceed the maximum amount allowed thereunder.

§ 5. Accepted Methods of Payment. You may remit payment by any of the following methods:

________

§ 6. Payment Deadline. Payment of the total amount set forth in § 4 must be received in good and collected funds no later than ________. Payment must be made by cash, money order, certified check, or other guaranteed funds; we reserve the right to refuse a personal check in satisfaction of this demand.

§ 7. Remittance Address. Please forward your payment to the following address:

________

§ 8. Dispute and Validation. If you believe this check was dishonored in error or you dispute the amount claimed, you must notify the undersigned in writing at the address above within ________ days of your receipt of this notice. Absent timely written dispute, the amount stated will be presumed valid.

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§ 10. Reservation of Rights. Nothing in this notice shall constitute a waiver of, or election among, any rights or remedies available to the undersigned at law or in equity, all of which are expressly reserved.

§ 11. Inquiries. Should you have any questions or require additional information regarding this matter, please contact me at ________ or ________.

Thank you for your prompt attention to this matter. We appreciate your cooperation in resolving this issue and look forward to receiving your payment by the date indicated above.

Sincerely,

_______________________________
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