Dispute Credit Card Charge

Date: ____________________
_________________________
_________________________
_________________________
[name and address of the company or financial institution that issued the credit card]
Re: Account number: _________________________
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 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.
[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 verify this dispute with the merchant and remove this item, and all late and interest charges attributed to this item, from my billing statement.

Sincerely,

___________________________________________________
Signature

___________________________________________________
Print Name:

___________________________________________________
Address:

___________________________________________________
Home phone: