1234, Main Street
Boston, MA 02123
04 April, 2005
<Recipient Address Goes Here>
Re: Error on Account No. <account number>
My last statement, dated <date>, contained a transaction in the amount of <$ dollar amount> with <payee name>. Please be advised that I did not charge this amount to my account and therefore wish to dispute it. Would you please check your records to verify the validity of this charge? If you should determine that this is, indeed, a valid charge on my account, I would appreciate it if you would provide me with a copy of the original charge slip bearing my signature.
Until I receive word from you as to the results of your investigation, I will be deducting the disputed amount from my current payment.
Thank you for your attention to this matter. If you should have any questions, please do not hesitate to contact me.
encl: <List of enclosed items goes here>