Affidavit for Service


In order to contract for Notary Certificate of Dishonor / Protest process, we need to have an Affidavit from you in our files requesting same. Here is a sample that you can use as a model.

Download .doc file here

In the template below, anything in square brackets ( [words] ) is instructions and needs to be removed. The “Etc., etc.” under #3 indicates that you continue on listing whatever documents you used. It should also be removed.



I, [Your name], a private living man/woman, over 18 years of age, being competent to testify and having first hand knowledge of the facts herein, declares under penalty of perjury of the laws of the united States of America,  that:

1.    I am making this request for Private Administrative Process without prior solicitation.

2.    On August 23, 2010, I received a demand for payment in the amount of $___________ from [whatever company/bank] which I disputed.

3.    On August 25, 2010, I sent a Conditional Acceptance (CA) [or whatever other document]  to [whatever company]

4.    [Company] did not answer within the required time frame and so on [date] I sent them a Notice of Fault with an additional 10 days to answer.

5.    [Company] did not answer within the required time frame and so on [date] I sent them a Notice of Default.

6.    In light of the dishonors noted above, I hereby request services for a notary public, to evidence the dishonor outlined above by re-presenting my Conditional Acceptance [or whatever and Affidavit to [whatever company]. Attached herewith is a copy of my Affidavit and dishonored CA [or whatever other documents             were used].

7.    The Notary on my paperwork will be held harmless.

8.    The Notary utilized for the re-presentation of my commercial paperwork has no interest in my matter.

9.    The Notary utilized I engage did not solicit me as a customer.

10.    I found the Notary through my own research and due diligence.

Further, Affiant sayeth naught.

Date:                                                            Name:__________________________________
[print name and address]


Use of a Notary on this document does not constitute an adhesion, nor does it alter my status in any manner. The purpose of the notary is verification and identification only and not for entrance into any foreign jurisdiction.


State of                                  )
) ss:
County of                               )

On this, the _____ day of _________________, 2015, before me, a notary public, the undersigned officer, personally appeared_______________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that s/he executed the same for the purposes therein contained.

In witness hereof, I hereunto set my hand and official seal.