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,