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 defective¹ 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，

　　_______________________________