Debt Dispute Form - H&R Block

This form must be completed and signed by the person(s) associated with the debt.

Debt Dispute Form

Client Information (Please Print)

Name:

Account #:

SSN:

Address:

City:

State:

Zip:

Phone:

E-Mail:

Debt Type (Check Appropriate Boxes) Tax Preparation Fees Refund Anticipation Loan ("RAL") Other / Unknown

Reason for the Dispute (Check Appropriate Boxes) Please provide additional information regarding the amount owed.

Bankruptcy

Date Filed:

Case #:

This debt does not belong to me. (I haven't used H&R Block in over five years.)

Other / Unknown

I paid the debt in full.

(Please include proof of payment ? receipts, bank statements, cancelled checks, etc.)

Payment Date: Payment Method:

Credit/Debit Card Payment Location:

H&R Block Office

Check/Money Order

Other

Mail

Online

Phone

Other

Additional Information (Please Print)

Signature:

Date:

Send to:

Mail:

Fax: 816-854-8257

H&R Block

PO Box 10121

Please include any supporting documentation available to

Kansas City, MO 64171-0121

support the dispute. Allow 2-4 weeks processing time.

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download