Credit Report Dispute Form printable pdf download

Credit Report Dispute Form

CREDIT REPORT DISPUTE FORM

Date:____________________________________

Please identify which agency(s) you

Name of Person Completing This Form:

used to identify the disputed credit

information

Work Phone

Home Phone

Cell Phone

_____ Equifax

_____ Experian

_____ TransUnion

Name and Other Information as shown on Credit Report Being disputed:

_____ Innovis

_____ Chex Systems

Last Name

First Name

Suffix

Date of Birth

SSN

_____ Other:_______________

Residence Address

City

State

Zip

Mailing Address

City

State

Zip

Date as shown on credit report

Account Number as shown on credit report

Year opened as shown on credit

report

Description of Credit Report Dispute

In order to help the bank research your specific dispute, please state why you disagree with the Bank's reported information and why you believe the

information is inaccurate. In addition to completing this form, attach all supporting documentation that substantiates the basis of your dispute. Examples

would be copies of the relevant portion of the credit report showing the item being disputed, a police report, a fraud or identify theft affidavit, a court order or

acount statements. The Bank will respond to this dispute within 30 business days by regular mail.

Bank Contact Information:

BlackRidgeBANK

Signature

Date

4040 42nd Street SW, Suite O

Fargo, ND 58104

701-364-9050

BANK RESPONSE

Signature

Date

Reviewed 3.2017