Know all men that I, A. B., landowner or householder of ........... in the district of ...................... at the request of C.D., there being no notary available, did on the ............. day of .................. 19......... at ........................... demand payment or acceptance from E.F., of the bill of exchange which or a copy of which is hereto annexed, to which demand he answered (state answer, if any) wherefore I now in the presence of G.H., and J.K., do protest the said bill of exchange.

A.B. ..........................

Witnesses:

G.H. .....................

J.K. .....................

N.B.- The bill itself or a copy of the bill and of everything appearing thereon should be annexed.