Form C-812 (9/2010)
STATE OF TEXAS
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 _____________________
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 _______________________
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
adequate funds on deposit at that time.
Bank Representative’s Signature
(Notary Seal) Address
SWORN TO AND SUBSCRIBED BEFORE ME, the undersigned a uthority, this the _______________
day of _________________ AD,__________________________ .
______________________________ __________ ___
Notary Public in and for the State of Texas