Fair Credit Billing Act Dispute Form: Your Guide to Resolving Billing Errors

FAIR CREDIT BILLING ACT DISPUTE FORM

PERSONAL INFORMATION

Full Legal Name: [FULL LEGAL NAME]
Account Number: [ACCOUNT NUMBER]
Billing Address:
[STREET ADDRESS]
[CITY, STATE ZIP CODE]
Phone Number: [PHONE NUMBER]
Email Address: [EMAIL ADDRESS]

CREDITOR INFORMATION

Creditor Name: [CREDITOR NAME]
Billing Dispute Address:
[CREDITOR BILLING DISPUTE ADDRESS]
[CITY, STATE ZIP CODE]

DISPUTE DETAILS

Merchant Name: [MERCHANT NAME]
Transaction Date: [TRANSACTION DATE]
Transaction Amount: $[AMOUNT]
Billing Statement Date: [BILLING STATEMENT DATE]

DISPUTE CATEGORY

(Please check the appropriate category)

• Unauthorized charge - I did not authorize this transaction
• Duplicate charge - I was charged twice for the same transaction
• Incorrect amount - The amount charged differs from my receipt/agreement
• Goods/services not received - I paid but did not receive the merchandise/service
• Goods/services not as described - The item/service received was defective, damaged, or not as described
• Cancelled recurring payment - I cancelled this recurring payment on [DATE]
• Credit not processed - The merchant agreed to issue a credit that has not appeared
• Paid by other means - I paid for this transaction using another method
• Other (please specify): _______________________________________________

DETAILED DESCRIPTION OF DISPUTE

I am writing to dispute a billing error on my account pursuant to my rights under the Fair Credit Billing Act (15 U.S.C. § 1666). The specific details of my dispute are as follows:

[PROVIDE DETAILED DESCRIPTION OF THE DISPUTE, INCLUDING RELEVANT DATES, COMMUNICATIONS WITH THE MERCHANT, AND ANY OTHER PERTINENT INFORMATION THAT SUPPORTS YOUR CLAIM]

PREVIOUS ATTEMPTS TO RESOLVE

I have made the following attempts to resolve this matter directly with the merchant:

1. Date of contact: [DATE]
   Method of contact: [PHONE/EMAIL/IN PERSON]
   Person contacted: [NAME/POSITION]
   Outcome: [DESCRIBE OUTCOME]

2. Date of contact: [DATE]
   Method of contact: [PHONE/EMAIL/IN PERSON]
   Person contacted: [NAME/POSITION]
   Outcome: [DESCRIBE OUTCOME]

LEGAL NOTICES AND REQUESTS

1. Timely Notification: I hereby certify that I am submitting this dispute within 60 days of the first billing statement on which the error appeared, as required by the Fair Credit Billing Act.

2. Written Notification Statement: This letter serves as written notification of a billing error under the Fair Credit Billing Act (15 U.S.C. § 1666).

3. Request for Investigation: I formally request that you investigate this disputed charge as required under the Fair Credit Billing Act and provide me with a written explanation of your findings.

4. Request for Documentation: Please provide copies of any documentation supporting the disputed charge, including but not limited to sales slips, invoices, delivery confirmations, or other relevant records.

5. Withholding Payment: In accordance with my rights under the Fair Credit Billing Act, I am withholding payment on the disputed amount while this investigation is pending. I understand that I remain obligated to pay any undisputed portions of my bill.

6. Credit Reporting Protection: I request that you not report the disputed amount as delinquent to any credit reporting agencies during the investigation period, as required by the Fair Credit Billing Act.

7. Response Timeframe: I understand that under the Fair Credit Billing Act, you must acknowledge receipt of this dispute within 30 days of receiving it, and you must resolve this dispute within two billing cycles (not to exceed 90 days) after receiving this notice.

SUPPORTING DOCUMENTATION

I have attached the following documentation to support my dispute:

• Copy of the billing statement showing the disputed charge
• Proof of payment (if applicable)
• Copies of communications with the merchant regarding this dispute
• Product/service documentation showing defects or failure to deliver as promised
• Other relevant documentation: _______________________________________________

CERTIFICATION AND SIGNATURE

I hereby certify that the information provided in this dispute form is true and accurate to the best of my knowledge. I understand that making false statements on this form may constitute fraud.

Signature: _______________________________________________

Date: _______________________________________________

DELIVERY INFORMATION

This dispute form should be sent to the creditor's billing dispute address listed above via certified mail with return receipt requested to document delivery. The certified mail tracking number is: [TRACKING NUMBER]

RECORD KEEPING INSTRUCTIONS

Please keep copies of all dispute documentation, including:

• This completed dispute form
• All supporting documentation submitted with this form
• Certified mail receipt and return receipt
• Any correspondence received from the creditor regarding this dispute
• Notes from any phone conversations regarding this dispute, including date, time, and the name of the representative

FOLLOW-UP INFORMATION

If you do not receive acknowledgment of this dispute within 30 days, or if the dispute is not resolved within 90 days, you may wish to:

1. Contact the creditor's customer service department for a status update
2. File a complaint with the Consumer Financial Protection Bureau (CFPB) at www.consumerfinance.gov
3. File a complaint with the Federal Trade Commission (FTC) at www.ftc.gov
4. Consult with a consumer rights attorney regarding additional legal remedies

IMPORTANT NOTICE: This form is provided as a template to assist consumers in exercising their rights under the Fair Credit Billing Act. The information contained herein does not constitute legal advice. For specific legal guidance regarding your particular situation, please consult with a qualified attorney.