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，