Company Name:
Account #:
No Knowledge of this Account
Company Name:
Account #:
No Knowledge of this Account
Account Not Reporting
Paid Before Collection/Write off
Included in Bankruptcy Included in Bankruptcy
Paid Before Collection/Write off
Account Not Reporting
Company Name:
Account #:
Other: Other:
Account #:
Company Name:
No Knowledge of this Account
No Knowledge of this Account
Included in Bankruptcy
Included in Bankruptcy
Paid Before Collection/Write off
Paid Before Collection/Write off
Account Not Reporting
Account Not Reporting
Other: Other:
ADDITIONAL COMMENTS
To investigate your dispute we will contact the source of the disputed information by phone and/or fax. Each source will
be advised as to the nature of your dispute and will be requested to verify the accuracy and/or the completeness of the
information they reported. If our investigation does not resolve your dispute you may add an explanation statement to
your report. All provinces allow a statement added of up to 100 words, except Saskatchewan - 200 words. If you would
like to add a statement, please print the statement on a separate sheet of paper and attach it to this form.
**RETURN THIS FORM TO THE ADDRESS LISTED AT THE TOP OF YOUR REPORT**
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I HAVE READ AND UNDERSTOOD THE ABOVE STATEMENTS AND HAVE PROVIDED INFORMATION THAT
IS, TO THE BEST OF MY KNOWLEDGE, TRUE AND ACCURATE. I AUTHORIZE YOU TO FOLLOW THE
PROCEDURES OUTLINED ABOVE IN AN ATTEMPT TO VERIFY THE INFORMATION THAT I AM DISPUTING.
Paid in Full
Paid in Full
Paid in Full
Paid in Full
DateSignature
End of Page 2
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