PDF Debt Dispute Form
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.
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