Bank Error Affidavit - Texas

Form C-812 (9/2010)
AFFIDAVIT
(BANK ERROR)
STATE OF TEXAS
COUNTY OF_______________
BEFORE ME, the undersigned authority, this day personally appeared ________ __________________________
,
who is a credible person, and who, after being by me duly sworn, did depose and say:
That I am an officer of ______________ located at ____________________________ _______.
(Name of Bank) (Address)
This is to certify that Check Number _____________ dated _____________________
(Month/Day/Year)
in the amount ______________ ___________ , made payable to ________________________ __
(Name of Permittee)
Drawn on the account of, or endorsed by ____________________ operator of _______________________ _____,
(Name of Representative) (Name of Retailer, Mixed Beverage, or
Private Club Permittee)
which was dishonored on the ___ ________ day of _______________________
(Month/Year)
by this bank for insufficient funds when presented for payment was the result of an error by this bank.
On the __________day of ________________ when the above check was presented for payment, there were
(Month/Year)
adequate funds on deposit at that time.
______________________________
Bank Representative’s Signature
_________________________________
(Notary Seal) Address
_________________________________
Phone Number
________________________________
Title
SWORN TO AND SUBSCRIBED BEFORE ME, the undersigned a uthority, this the _______________
day of _________________ AD,__________________________ .
______________________________ __________ ___
Notary Public in and for the State of Texas
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