SAMPLE - DISPUTED BALANCE NOTICE FORM

DISPUTED BALANCE NOTICE

We are in receipt of your statement dated _, 2___, 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 _, 2___,.
     ____ 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,