DISPUTE FORM

CREDIT REPORT DISPUTE FORM First Name: [FIRST NAME] Middle: [MIDDLE] Last: [LAST NAME] Suffix: [ ] Jr. [ ] Sr. Date of Birth (MM/DD/YYYY): [MM]/[DD]/[YYYY] Address: [YOUR ADDRESS] City: [CITY] State: [STATE] Zip: [ZIP] Previous Address (if moved within past two years): Address: [PREVIOUS ADDRESS] City: [CITY] State: [STATE] Zip: [ZIP] Telephone Number: [YOUR PHONE] Social Security Number: [SSN] Signature: [YOUR SIGNATURE] Date: [DATE] --------------------------------------------------------------- DISPUTED ITEM #1 --------------------------------------------------------------- Creditor Name: [CREDITOR NAME] Account Number: [ACCOUNT NUMBER] Dispute Reason(s) — check all that apply: [ ] Not My Account [ ] Account Status Not Correct [ ] Late Payments [ ] Paid in Full [ ] Identity Theft [ ] Incorrect Balance (Approx. Correct Balance): [AMOUNT] [ ] Other (Explain): [EXPLANATION] --------------------------------------------------------------- DISPUTED ITEM #2 --------------------------------------------------------------- Creditor Name: [CREDITOR NAME] Account Number: [ACCOUNT NUMBER] Dispute Reason(s) — check all that apply: [ ] Not My Account [ ] Account Status Not Correct [ ] Late Payments [ ] Paid in Full [ ] Identity Theft [ ] Incorrect Balance (Approx. Correct Balance): [AMOUNT] [ ] Other (Explain): [EXPLANATION] --------------------------------------------------------------- ADDITIONAL INFORMATION TO BE CORRECTED --------------------------------------------------------------- (For example: Name, Address, Employer) [ADDITIONAL INFORMATION] [REPEAT DISPUTED ITEM BLOCKS AS NEEDED] Remember to make a copy for your records.