YOUR NAME
Street Address
City, State, Zip
Phone Number (with area code)
Fax Number: if available
Email: if available
YOUR NAME, IN PRO PER
SUPERIOR COURT OF THE STATE OF CALIFORNIA
FOR THE COUNTY OF SAN DIEGO
NAME OF PLAINTIFF(S)
Plaintiff(s),
vs.
NAME OF DEFENDANT(S),
Defendant(s).
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Case No.:
DOCUMENT TITLE (e.g., NOTICE OF
MOTION AND MOTION FOR STRIKING
PORTIONS OF COMPLAINT)
DATE: (date of hearing)
TIME: (time of hearing)
DEPT: (department number)
Judge: (name of hearing judge)
Dept: (department number)
Action Filed: (date)
Trial Date: (Date or Unassigned)
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.
1
INSERT DOCUMENT TITLE (e.g., MOTION TO STRIKE)
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
Your signature
YOUR NAME
In Pro Per
2
INSERT DOCUMENT TITLE (e.g., MOTION TO STRIKE)