"STATE OF ____________________
COUNTY OF ____________________
____________________, being first duly sworn on oath, deposes and states that he/she is at least eighteen (18) years of age and that on (date) ____________________, 2 ____________________, he/she served the attached Notice of Dishonor by placing a true and correct copy thereof securely enclosed in an envelope addressed as follows:
____________________
____________________
____________________
and deposited the same, postage prepaid, in the United States mail at ____________________ ____________________.
____________________
(signature)
Subscribed to and sworn before me, this the ____________________ day of ____________________, 2____________________.
____________________
(Notary Public)
My commission expires:
(SEAL)"
Miss. Code § 97-19-57