Dispute Credit Card Charge
Date: 	

	
	
[name and address of the company or financial institution that issued credit card]
Re: Account number: 
Names(s) on account: 	
To Whom It May Concern:
I am writing to dispute the following charge that appears on my billing statement dated 	 .
Merchant’s name: 	
Amount in dispute: 	 . 
I am withholding payment of $ 	 , which represents the unpaid balance on the disputed item.
I am disputing this amount for the following reason(s): 						 .
As required by law, I have tried in good faith to resolve this dispute with the merchant. [Describe your efforts] 					 .
[For purchases made with a credit card, such as Visa or MasterCard, not issued by the seller]:
[  ] This purchase was for more than $50 and was made in the state in which I live or within 100 miles of my home. Please remove the charge for this item, and all associated late and interest charges from my account.
Sincerely,
Signature 	 
Printed or typed name 	
Address 	
	
Home phone