FORM 6

PROTEST FOR NON-PAYMENT OF A NOTE PAYABLE AT A STATED PLACE

(Copy of Note and Endorsements)

On this .................... day of ...................., in the year 19......, I, A.B., notary public for the Province of ...................., dwelling at ...................., in the Province of ...................., at the request of ...................., did exhibit the original promissory note, whereof a true copy is above written, unto .................... the promisor, at ...................., being the stated place where the said note is payable, and there, speaking to .................... did demand payment of the said note, unto which demand he answered: “....................”.

Wherefore I, the said notary, at the request aforesaid, have protested, and by these presents do protest against the promisor and endorsers of the said note, and all other parties thereto or therein concerned, for all costs, damages and interest, present and to come, for want of payment of the said note.

All of which I attest by my signature.