Fillable Printable Bank Error Affidavit - Texas

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