On this __________day of_________________1998, a check (demand for payment) drawn on the undersigned bank was presented by _________________________for payment on the account of ___________________________the same being account number: _________________, in the amount of $_________________. 

  1. The undersigned bank officer hereby certifies that, at the time of presentment and demand for payment, the balance in said account was sufficient cover the face amount of the check.
  2. The person presenting the check for payment exhibited proper identification in the form of a _________________, sufficient to identify him or her as the named payee.
  3. The money on deposit in said bank account belongs to the depositor and not to the bank on which the check was drawn.
  4. The undersigned bank officer, individually, and on behalf of the bank, refused to cash said check solely because the named payee thereon refused to provide the bank with his or her fingerprint of thumbprint.
  5. It is the express policy of this bank that it will not cash or pay any check drawn on aly of tis depositors' accounts unless the named payee provides the bank with a fingerprint or thumbprint in addition to exhibiting other valid identification.
  (Name of Bank) 

  (Street Address of Bank) 

(City and State) 

(Name and title of bank officer)