Date

Dear Check Writer:

You are hereby notified that a check numbered _____ in the face amount of
$ ___________, issued by you on ____________ drawn upon _________ bank, and payable to _______________, has been dishonored. You have 10 days from receipt of this notice to tender payment of the full amount of such check plus a service charge which may not exceed the greater of 27.50 or 5% (but not more than $250) of the amount due.

Unless this amount is paid in full within the time specified above, the holder of such check may turn over the dishonored check and all other available information relating to this incident to the Prosecuting Attorney for criminal prosecution.

Closing,

Your name/address