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，
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