Answer:
The notice is published as Appendix A to the regulation, 31 CFR 212. All you need to do is copy and paste it into a Word document and then make the adjustments required based on state law and bank policy.
I suggest you develop two forms, one to use when there are no funds subject to hold and another when there are. It makes the notice simpler and easier to understand.
First published on BankersOnline.com 10/10/11