Please provide your accurate client and account information to help us process your dispute efficiently.
Legal Entity Name
Client Account Number
Primary Contact Person Full Name
Contact Person Job Title
Contact Email Address
Contact Phone Number
Assigned Account Manager Name (if known)
How long have you been a client (in months)?
Provide specific details about the invoice(s) in dispute. You can dispute multiple invoices in a single request if they share similar issues.
Invoice(s) in Dispute
Invoice Number | Invoice Date | Due Date | Total Invoice Amount | Amount in Dispute for This Invoice | Purchase Order Number (if applicable) | ||
|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | ||
1 | INV-2025-00123 | 1/15/2025 | 2/15/2025 | $15,000.00 | $3,500.00 | PO-7890 | |
2 | INV-2025-00145 | 1/28/2025 | 2/28/2025 | $8,200.00 | $8,200.00 | PO-7890 | |
3 | |||||||
4 | |||||||
5 | |||||||
6 | |||||||
7 | |||||||
8 | |||||||
9 | |||||||
10 |
Total Disputed Amount Across All Invoices
Are you withholding payment of the disputed amount only, while paying the undisputed portion?
What amount have you already paid or intend to pay (undisputed portion)?
Please explain your payment withholding strategy:
Categorize your dispute to help us route it to the appropriate resolution team. Please select the primary reason that best describes your dispute.
Primary Dispute Category
Pricing or Rate Discrepancy
Service or Product Quality Issue
Quantity or Delivery Discrepancy
Duplicate Billing
Contract or Agreement Misalignment
Tax or Surcharge Error
Credit or Adjustment Not Applied
Other (please specify)
Describe the pricing discrepancy: What was the agreed rate vs. billed rate?
Rate the severity of quality issues for each aspect:
Not Applicable | Minor Issue | Moderate Issue | Major Issue | Critical Issue | |
|---|---|---|---|---|---|
Did not meet specifications | |||||
Defective or non-functional | |||||
Incomplete deliverables | |||||
Poor workmanship | |||||
Non-compliance with standards |
Explain the quantity or delivery discrepancy: What was ordered vs. what was delivered/billed?
Provide the original invoice number that was duplicated:
Explain how the billing does not align with the contract terms:
Describe the tax or surcharge error and what should be the correct amount:
Explain what credit or adjustment was expected but not applied:
Please specify the other reason for dispute:
Urgency Level: How critical is this dispute resolution to your operations?
How would you rate your current satisfaction level with our billing accuracy?
Provide a detailed breakdown of disputed line items. This helps our team investigate specific charges rather than just total amounts.
Do you have a line-item breakdown of the disputed charges?
Detailed Disputed Line Items
Line Item Description | Invoice Number | Billed Quantity | Billed Unit Price | Billed Total | Correct Quantity (if different) | Correct Unit Price (if different) | Correct Total | Disputed Amount per Line | ||
|---|---|---|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | G | H | I | ||
1 | $0.00 | $0.00 | $0.00 | |||||||
2 | $0.00 | $0.00 | $0.00 | |||||||
3 | $0.00 | $0.00 | $0.00 | |||||||
4 | $0.00 | $0.00 | $0.00 | |||||||
5 | $0.00 | $0.00 | $0.00 | |||||||
6 | $0.00 | $0.00 | $0.00 | |||||||
7 | $0.00 | $0.00 | $0.00 | |||||||
8 | $0.00 | $0.00 | $0.00 | |||||||
9 | $0.00 | $0.00 | $0.00 | |||||||
10 | $0.00 | $0.00 | $0.00 |
Since you don't have a line-item breakdown, please describe the dispute in your own words with as much detail as possible:
Upload all relevant supporting documents. Evidence strengthens your dispute and accelerates resolution. Acceptable formats: PDF, JPG, PNG, DOC, XLS, CSV.
Upload the disputed invoice(s) (clearly marked with disputed items)
Upload Purchase Order(s) or Contract Agreement
Upload Delivery Receipts, Timesheets, or Proof of Performance
Upload Email Correspondence or Written Communications Related to This Issue
Upload Any Other Relevant Supporting Documents (quality reports, photos, specifications, etc.)
Do you have written approval or authorization for any deviations from the original agreement?
Upload the written approval or authorization document
Provide a timeline of key events leading to this dispute (e.g., delivery dates, communication attempts, issue discovery):
Clearly state what adjustment you are requesting and your proposed resolution path.
What type of fee adjustment are you requesting?
Full Credit/Refund of Disputed Amount
Partial Credit/Refund (reduced amount)
Invoice Reissue with Corrected Amount
Future Invoice Credit
Service Re-performance at No Charge
Discount on Future Services
Other Compensation
What partial amount do you believe is fair and acceptable?
Specify how you would like the future credit to be applied:
Describe what re-performance is required and acceptable timeline:
Specify the discount percentage or amount and applicable period:
Describe the alternative compensation you are seeking:
Provide your justification for the requested adjustment and why you believe this is a fair resolution:
Are you open to a negotiated settlement that differs from your requested adjustment?
What are your negotiation parameters or minimum acceptable terms?
Help us understand your preferred approach and urgency for resolving this dispute.
Preferred Resolution Method
Direct Negotiation with Account Manager
Formal Mediation Process
Arbitration
Executive Escalation
Written Correspondence Only
Joint Review Meeting (in-person or virtual)
What is your desired resolution date?
Rate the impact of this dispute on your business relationship with us
Will you continue to place new orders or engage in new projects while this dispute is pending?
If you have worked with other vendors for similar services, what would be a typical resolution timeline in your experience?
Provide context about your history with us and how this dispute fits into the broader relationship.
Have you had any previous invoice disputes with us in the past 12 months?
Previous Disputes (Last 12 Months)
Previous Invoice Number | Resolution Date | Disputed Amount | Final Resolution Amount | Were you satisfied with the resolution? | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
1 | ||||||
2 | ||||||
3 | ||||||
4 | ||||||
5 |
Rate your overall experience with us across these dimensions (1 = Poor, 5 = Excellent):
Billing Accuracy | |
Service Quality | |
Communication Responsiveness | |
Contract Adherence | |
Value for Money | |
Dispute Resolution Process |
Has this dispute affected your payment history with us?
Explain how your payment pattern has changed and why:
Describe any external factors (market conditions, regulatory changes, internal budget constraints) that may be influencing this dispute or its urgency:
By submitting, you certify this information is accurate and authorize us to review account documentation and contact you regarding this dispute.
I certify that I am authorized to submit this dispute on behalf of the client entity and that all information provided is true and accurate.
I consent to the collection, use, and storage of the data provided in this form for dispute resolution purposes.
I acknowledge that submitting this dispute does not automatically halt any collection activities on the undisputed portion of the invoice(s).
Do you require a formal written response acknowledging receipt of this dispute within 5 business days?
Authorized Signature
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