1234, Main Street
Boston, MA 02123
04 April, 2005
<Recipient Address Goes Here>
Re: Error on Account No. <Account number>
Recently, when I checked my account statement, I found a transaction in the amount of [$..] with [payee name].
Please note that I am not aware of this charge, I never authorized this charge, so I dispute it.
I request you to please check the records and verify the validity of this single charge. And, if you come to know that it is a valid charge, then I would appreciate it if I can get the original charge slip with my signature.
Until this matter is solved, I will deduct the disputed amount from my payments.
Thank you for your kind attention to this matter.
encl: <List of enclosed items goes here>