CERITIFCATE OF NON-RESPONSE

(CERTIFICATE OF PROTEST)

RE: Acceptance by John Henry Doe of complain on case # [state case number] JOHN H DOE

This Protest Certificate is presented as evidence of dishonor pursuant to legal authority as Codified in
the Official Code of Georgia Annotated (O.C.G.A) 11-1-202, 11-3-505, 24-4-23, and 24-7-23.

John Doe, am the notary who verified John Henry Doe’s dishonor of John Henry Doe’s Notice
acceptance, for JOHN H DOE, pursuant to state law regarding evidence of dishonor GA 11-3-505. I
certify the following:

On, [give date] the record shows I mailed John Doe’s Notice of Acceptance with attachments, dated
[give date] to Dave Brown at ABC Agency at [ADDRESS], by certified mail package # [CERT 3]
RRR, as verified by Certificate of Service.

On, [give date] the records shows I mailed a NOTICE OF BREACH to Dave Brown at ABC Agency
at [give address], by certified mail package # [CERT #] RRR, as verified by Certificate of Service.

After acceptance of both mailings, Dave Brown, for ABC Agency, refused to send the confirmation
that account for case # [give case #] has been adjusted and settled, nor a notice of dishonor form a
qualified third party excusing his refusal, in the ten (10) days following the second mailing.

Dave Brown, for ABC Agency, did not cue his dishonor. He gave no reason for his refusal to confirm
the adjustment and settlement of the account or send a notice of dishonor.

Herefore, based on the foregoing facts, I certify that Dave Brown, for ABC Agency, dishonored John
Henry Doe and me through his non-response, and did thereby agree that John Henry Doe accepted the
subject complaint for case # [give case #], returned the complaint, exchanged his exemption for the
charge of the associated charges, presented an authorization for the use of his credit to setoff all
associated court charges, included processing instruction, included a statement of account showing a
zero balance, sent a letter of credit to John Snow as notice that exemption # [give exemption #] was
being used to settle account [give account #]

Further, Dave Brown, agreed that his refusal to send the written confirmation of the settlement of
account # [type account #] or a notice of dishonor form a qualified third party, in no way negates the
fact that said account settled and closed, that he and the agency he represents have no capacity to
pursue collection on said account, and that further pursuit of collection is agreement that Dave Brown
and ABC Agency collectively and severably owe JOHN H DOE may take all necessary steps to
secure its claim to the debt owed to it and to collect.

Dated: _________________

_______________________________(seal)
Notary Public

Stamp

Notary Name, Notary Public

Notary Address
City, State, Zip

Void Where Prohibited By Law

CERITIFCATE OF NON-RESPONSE
(CERTIFICATE OF PROTEST)

Void Where Prohibited By Law