In order to contract for Notary Certificate of Dishonor / Protest process, we need to have an Affidavit from you in our files requesting same. Here is a sample that you can use as a model.

VERIFIED DECLARATION IN THE NATURE OF AN AFFIDAVIT

I, [Your name], a living soul, over 18 years of age, being competent to testify and having first hand knowledge of the facts herein, declares under penalty of perjury of the laws of the united States of America,  that:

1.    On August 23, 2010, I received a demand for payment in the amount of $___________ from [whatever company/bank] which I disputed.

2.    On August 25, 2010, I sent a Conditional Acceptance (CA) [or whatever other document]  to [whatever company]

3.    [Company] did not answer within the required time frame and so on [date] I sent them a Notice of Fault with an additional 10 days to answer.

and so on...

In light of the dishonors noted above, I hereby request your services as a notary public for the Commonwealth of Pennsylvania, to evidence the dishonor outlined above by re-presenting my Conditional Acceptance and Affidavit to [whatever company]. Attached herewith is a copy of my Affidavit and dishonored CA [or whatever other documents were used].

Further, Affiant sayeth naught.

Date:                                    Name:__________________________________
                                                       [print name and address]






State of                                  )
                                              ) ss:
County of                               )

On this, the _____ day of _________________, 2011, before me, a notary public, the undersigned officer, personally appeared_______________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that s/he executed the same for the purposes therein contained.

In witness hereof, I hereunto set my hand and official seal.