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$________________________ (date)


To:  ___________________ (drawee)

       ___________________ (address)



__________________ (At sight, or __________ (__________) days after sight, or __________ (__________) days after date, or on ____________ (date), or on demand) pay __________________ (to the order of __________, or to __________ or order, or to bearer, or to __________________ or bearer) __________ Dollars ($__________), and charge the sum paid to the account of __________________ (drawer).





(Signature of Drawer)


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