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ARG
ASI
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Dispute a Bill
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P: 503.236.6225
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Dispute a Bill
To dispute a bill, please complete the following form.
Fields marked in
red
are required.
Please enter your ACCENT account number
(if known)
:
Please enter your full name
(Required)
First Name:
*
Last Name:
*
MI:
*
(Required)
Is the bill you are disputing for yourself?
Select
Yes
No
*
If "No," are you a...
Select
Spouse
Legal Guardian
Legal Representative
Other
If disputing on behalf of a business, enter business name below:
Enter disputing party´s address:
(Required)
Address Line 1:
*
Address Line 2:
City:
*
State:
*
Select
AL
AK
AR
AZ
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
*
Enter additional address
(if any)
:
Address Line 1:
Address Line 2:
City:
State:
Select
AL
AK
AR
AZ
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
(Required)
Phone Number:
*
Type of phone:
Home
Work
Cell
Other
May we contact you at this number?
Yes
No
(Required)
Enter your email address:
‹ Enter valid email
How may we contact you?:
Phone
Email
Both
(Required)
Please describe in detail your reasons for disputing this bill:
*
I would like a copy of this dispute sent to my email address:
By clicking "Submit," I acknowledge that Account Control Consultant Enterprises, Inc. is a collection agency and any information obtained will be used for the purpose of collecting a debt.