Dispute Notice Form - North Dallas Bank & Trust Co. - 2015
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5North Dallas Bank & Trust
Co. Loan Operations
Department
12900 Preston Rd
Dallas, Texas 75230
Fax (972) 716-7297
Dispute Notice Form
Consumer Information
Individual Account
Joint Account
(Print)
FIRST NAME
MIDDLE INITIAL
LAST NAME
SOCIAL SECURITY NUMBER
DATE OF BIRTH
PHONE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
Joint Consumer Information
(If applicable) (Print)
FIRST NAME
MIDDLE INITIAL
LAST NAME
SOCIAL SECURITY NUMBER
DATE OF BIRTH
PHONE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
Dispute Information
(Print)
ACCOUNT # IN DISPUTE
REASON FOR DISPUTE
CONSUMER COMMENTS
** Please attach all relevant documentation and mail to the address on this form. You will be notified
within 30 days from receiving a completed Consumer Dispute Form as specified below:
Check one of the following:
U.S. Mail Address:
Email Address:
Fax Number:
DATE _____________________ LENDER SIGNATURE _____________________________________
Revised - June 2015
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Parent category: Financial