Document No: RExxxxxxxxUS-JRxxxx

From: John-Doe
c/o Notary, Notary Public/Acceptor/Witness
xx Any Street
City, State zip

To: BANK
Attn: CEO’s name
Address
City, state zip

Re: BANK/Account Number: XXXXXXXXXXX

PRIVATE
THIS IS NOT A PUBLIC COMMUNICATION
BUT MAY BE MADE PUBLIC BY FAILURE TO PERFORM
TO SATISFY THE CONCURRENT PUBLIC RECORD
Applicable to all successors and assigns
Silence is Acquiescence, Agreement, Dishonor
This is a self-executing contract

NOTICE TO THE AGENT IS NOTICE TO THE PRINCIPAL

NOTICE TO THE PRINCIPAL IS NOTICE TO THE AGENT

GOOD FAITH STATEMENT OF ACCOUNT

The following is issued pursuant to NY UCC § 9-210. Alleged debtor JOHN DOE has made demand
upon BANK for a VERIFIED STATEMENT OF ACCOUNT, including the source and nature of the
consideration provided by BANK.This is a GOOD FAITH STATEMENT OF ACCOUNT issued by
JOHN DOE regarding Account Number XXXXXXXXXXX with BANK. The balance on Account
Number XXXXXXXXXXX, in the name of JOHN DOE, is: $0.00

PLEASE TAKE NOTICE: Failure to rebut JOHN DOE’s accounting with a correcting VERIFIED
STATEMENT OF ACCOUNT from BANK within 14 days shall be BANK admission / tacit procuration
to the truth and correctness of the JOHN DOE GOOD FAITH STATEMENT OF ACCOUNT and is
lawfully and legally binding on BANK and all successors and assigns as ultimate fact; and that this
GOOD FAITH STATEMENT OF ACCOUNT may be employed in any private and/or public record
regarding BANK Account Number XXXXXXXXXXX; and that BANK further agrees that it may not
argue, controvert, or protest the finality of JOHN DOE’s GOOD FAITH STATEMENT OF
ACCOUNT to which BANK has agreed; and that BANK irrevocable agreement shall be fully binding
in any court in the UNITED STATES without future protest or objection by BANK or by any other
representative or agent that represents BANK concern; and that BANK further agrees to JOHN DOE
closing of the account on the public side of the ledger, via a, ex parte motion to dismiss or an ex parte
application in the appropriate court for a public summary or declaratory judgment.

GOOD FAITH STATEMENT OF ACCOUNT

VOID WHERE PROHIBITED BY LAW
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 Document No: RExxxxxxxxUS-JRxxxx

PLEASE TAKE FURTHER NOTICE: All reply communications are only to be forward to the above-
named Notary Witness. ALL OTHER DELIVERY ADDRESSES WILL BE CERTIFIED AS
DEFECTIVE.

Prepared and submitted by:

JOHN DOE

By:______________________________________
John-Doe, L.S., Authorized Signatory
NY UCC § 3-403(1); NY UCC § 1-207 / UCC § 1-308

STATE OF YOUR STATE )

) ss.: ACKNOWLEDGEMENT/JURAT
COUNTY OF YOUR COUNTY )

On May __, 2010 before me, ___________________________

VIA CERTIFIED MAIL: Article #: ___________________________________

personally appeared: John-Doe, who proved to me on the basis of satisfactory evidence to be the man
whose name is subscribed to the within instrument and acknowledged to me that he executed the same in
his authorized capacity, and that by him signature on the instrument the person, or the entity upon behalf
of which the person acted, executed the instrument under the penalty of perjury.

I certify under PENALTY OF PERJURY under the laws of the State of Your State that the foregoing
paragraph is true and correct.

WITNESS my hand and official seal.

Signature ________________________________________ (Seal)

Notary Public

GOOD FAITH STATEMENT OF ACCOUNT

VOID WHERE PROHIBITED BY LAW
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