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. Pursuant to Pennsylvania law you have 10 days from receipt of this notice to tender payment of the full amount of such check plus a service charge of $____, the total amount due being $________.

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 District Attorney for criminal prosecution.

Closing,

Your name/address