"You are hereby notified that the following instrument(s):

Number: ........... Date: ............ Amount: ............. Name of Bank: ................. drawn upon ....................... and payable to ............................., (has)(have) been dishonored. Pursuant to Maine law, the Maine Revised Statutes, Title 17-A, section 708, subsection 2, you have 5 days from receipt of this notice to tender payment of the total amount of the instrument(s) plus the applicable service charge(s) of $.............(............dollars and ............cents) and any fee charged to the holder of the instrument(s) by a bank or financial institution as a result of the instrument(s) not being honored, the total amount due being $..........(..........dollars and..........cents). Pursuant to Title 17-A, section 708, subsection 2, unless this amount is paid in full to ...........within 5 days after the actual receipt of this notice of dishonor, your failure to pay the amount owed gives rise to a permissible inference under the Maine Rules of Evidence, Rule 303 that you knew that your instruments(s) would not be honored. Your failure to pay the amount owed could result in a report to a law enforcement agency for investigation and possible criminal prosecution for negotiating a worthless instrument in violation of Title 17-A, section 708, subsection 1." ’