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Dear ______________________:

This statutory notice is provided pursuant to section 97-19-57 Mississippi Code of 1972. You are hereby notified that a check, draft, or order numbered __________, has been dishonored. Pursuant to Mississippi law, you have fifteen (15) days from receipt of this notice to tender payment of the full amount of such check, draft, or order, plus a service charge of $40.00, the total amount due being $__________. Unless this amount is paid in full within the time specified above, the holder may assume that you delivered the instrument with intent to defraud and may turn over the dishonored instrument and all other information relating to this incident to the proper authorities for criminal prosecution.

 

Yours truly,