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This is a Georgia Jury Instructions form that can be used for Accord and Satisfaction.
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04.042 Accord and Satisfaction; Uncashed Check When a check is tendered and delivered to a creditor in a stated amount in full and complete satisfaction of a claim and the check is retained by the creditor, whether the amount of the claim is established or uncertain, the following rule of law applies: if it is not presented for payment to be charged to the account of the maker, it does not amount to an accord and satisfaction of the claim as a matter of law, but it is a question of fact. This rule applies unless the creditor acknowledges receipt and retention of the check for the purpose tendered; in which case, it does amount to an accord and satisfaction. Ryan v. Progressive Retailer Publishing Co., 16 Ga. App. 83 (1915) Thompson v. Hecht, 110 Ga. App. 505, 506 (1964) American Oil Co. v. Studstill, 230 Ga. 305 (1973)