NOTICE OF DISHONORED CHECK
DATE _________
NAME OF ISSUER _________
STREET ADDRESS _________
CITY AND STATE _________
You are according to law hereby notified that a check or instrument numbered _________ and dated _______________________________________ 20 _________ , drawn on _____________________________________ (bank or other financial institution) of _____________________________________ , in the amount of _____________ has been returned unpaid with the notation that the payment has been refused because of rule. Within thirty (30) days from the mailing of this notice, you must pay or tender to _____________________________________
(holder)
at _____________________________________________________________________ sufficient money to pay the check
(address of holder)
draft or instrument in full. If payment of the above amount is not made within thirty (30) days of the mailing of this notice of dishonor, you may be liable under § 6-42-3, in addition to the amount of the check, draft, or other instrument, and a collection fee of twenty-five dollars ($25.00), for an amount of up to three (3) times the amount of the check, draft, or other instrument, but in no case less than two hundred dollars ($200) and not more than one thousand dollars ($1,000).
_____________________________________
(signature of holder)
R.I. Gen. Laws § 6-42-2