Disputed Balance Notice

Date:

To: (Creditor)

We are in receipt of your statement dated ___________, 20 _, indicating an account balance of $ _______.

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

_____ 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 rights of return and credit.

_____ Other (Describe)

Please adjust our account.

Very truly,

___________________________

FORM15

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