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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,

_______________________________