[DATE, ex. Wednesday, June 11, 1998]
 

[NAME, COMPANY AND ADDRESS, ex.
John Smith
XYZ Bank
1234 First Street
Suite 567
Anycity, Anystate  85245]
 

Dear [NAME, ex. John Smith],
 

In reference to your bank statement of [DATE, ex. July 30, 1998] for our [savings / checking] account #[ACCOUNT NUMBER], I kindly request that a copy of the debit memo for the following service charge be forwarded to me:

DATE            AMOUNT
[LIST DATE & AMOUNT, ex
5/5/98          $21.00] 

As we are unable to reconcile this charge, I would appreciate any clarifying information you may have.

Sincerely, 

[YOUR NAME, ex. Jill Jones]