Disputed Balance Notice

Date: _




To: _




We are in receipt of your statement dated _, 20_,

indicating an account balance of $_.

We dispute said balance for the reason(s) checked.


____ Goods billed for have not been received.

____ Prices are in excess of agreed amount.

____ Prior payment made in the amount of $_ on _, 20_.

____ Goods were unordered.

____ Goods were defective as per prior notice.

____ Goods are available for return as per our right of

return and credit.

____ Other (Describe) _


Please adjust our account.



Very truly,





_______________________________