Credit Report Dispute and Investigation Form

Last Name: _________________ First Name: __________________ Middle Name/Initial: _____ Suffix: ______

Current Address: ______________________________________________ Date of Birth: _____________

City: ___________________ State: ________________ Zip Code: ___________

Social Security Number: _________________ Account Number: ___________________________________

Reason(s) you are requesting investigation of information on your credit report:

☐Inquiry appears on my credit report that I do not recognize or believe is incorrect

☐A payment is reporting inaccurately

☐The account is not mine. (Example: Unknown account, account belongs to someone with a similar name or account belongs to a

family member and you are not associated with the account)

☐I am a victim of fraud or ID theft

☐The balance, past due amount or other amount is reporting inaccurately

☐My account status is reporting inaccurately

☐The date opened/closed, date of last payment or other date is reporting inaccurately

☐My account is showing in dispute, and I did not dispute information on my credit report

☐A bankruptcy, settlement or charge-off is reporting inaccurately

☐Other

Please provide a detailed explanation and supporting documentation as to why you are disputing information on your credit

report (Please include the following if applicable):

• The Credit Reporting Agency(s) reporting the disputed information (Equifax, Experian, TransUnion)

• The name of the field(s) on your credit report which you are disputing

• The date(s) of any late payments/delinquencies being reported which you are disputing

• Date of the inquiry as reflected on your credit report and the name of each Consumer Reporting Agency displaying the

inquiry

• Detailed explanation as to why the information is incorrect

• If available, a copy of your credit report highlighting the disputed information

Supporting documentation provided:

☐Credit report including the disputed information

☐Evidence showing account was paid on time (if the dispute concerns a late payment(s))

☐Other (provide description below)

Dispute Explanation (Please attach additional explanation if needed):

We’ll research your dispute and let you know if we agree or disagree with you. If we agree with you, we’ll contact each Consumer

Reporting Agency we reported to and request a correction.

Customer Signature: _______________________________ Today’s Date: ____________________

Please select the type of account you are disputing, to obtain the correct mailing address. If uncertain as to the type of card or

account to select, please contact the number on the back of your card or on your statement. If you do not have a credit card or Citi

account statement, please refer to address listed on your Credit Report.

Note: Sending to the information to the wrong address may cause a delay in processing your dispute.

Citi Cards (examples include

AAdvantage, Double Cash, Simplicity,

etc..)

Citi Brands Credit Bureau

Disputes

PO Box 6241

Sioux Falls, SD 57117

Costco Cards

Costco Credit Bureau Disputes

PO Box 6190

Sioux Falls, SD 57117