Disputed Balance Notice Form

Question

DISPUTED BALANCE NOTICE
                                   Date: _

To: _

     We are in receipt of your statement dated _, 19_,
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 _, 19_.
     ____ 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,

                                   _______________________________