（ ） 字第 号
兹应票据持有人 的要求（票据原件附后），本公证员于 年 月 日向票据付款人 提示原票据，并要求其付款，遭其拒绝。
据此，本公证员特立此证书证实该票据项下付款确实遭到汇票付款人拒绝。
中华人民共和国 省 市公证处
公证员 （签名）
年 月 日
Protest Certificate
On the day of in the year ， at the request of ， holder of the bill of exchange， a true copy of which is here to annexed， I， Notary Public， duly authorised， produced and exhibited the said original bill to ， on whom the said bill is drawn and demanged payment thereof， and he answered that it would not be paid.
Whereupon， I， the said Notary， at the request as atoresaid， issue this certificate attesting that the payment of the said bill has been refused by the drawee.
Notary：___________________(Signature)
Notary Public Office(Seal)
Province
The People's Republic of China
(month)， (day)，____(year)
