Notice of Disputed Account Form

Complete the form fields below to generate a Notice of Dispute that you can print and use for when you disagree with an invoice amount from a merchant or supplier from whom you've purchased goods.

Click here for completed sample. Bolded items are examples of completed fields from this form. This example shows all options checked off and all additional information filled in. You don't have to check everything off and form fields that are not applicable in your case does not have to be completed—they simply will not appear on your completed Notice of Disputed Account.

The current date is filled in automatically by the program creating the printable form. The program also will automatically calculate the credit due back to you/your company, so you don't have to worry about it.

Your Name:
Your Title:
Your Company:
Your Street Address:
Your City:
State/Province:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington Washington D.C. West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick New Foundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory (Select a state or Canadian province)
Your Zip/Postal Code:
Your Country:	U.S.A. Canada
Company:	(Company name of supplier/merchant)
Contact:	(If you know the contact person's name)
Company Address:
Company City:
Company State/Province:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington Washington D.C. West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick New Foundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory (Select a state or Canadian province)
Company Zip/Postal Code:
Company Country:	U.S.A. Canada
Account Number:
Invoice Number:
Invoice Date:
Invoice Amount:
Check off from the following list what is applicable to your situation. If you've checked an item that requires additional information, complete those fields as well.
We believe the invoice is in error as follows: Goods received were defective, as previously indicated. We claim credit in the amount of Goods billed for have not been received. We claim credit in the amount of Prices are greater than amount agreed. We claim credit in the amount of . Prior payments of made on have not been credited to the account. Goods are available for return and credit per our agreement. Goods shipped were never ordered, and await return per your shipping instructions. Other:
The following text box lets you further detail why you feel the invoice is inaccurate or add other comments.
Other comments:	(Describe the reason you feel the invoice is inaccurate)

This is not a substitute for legal advice, and it is suggested that an attorney be consulted.