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,


_____________________________