Information Request on Disputed Charges: $25.00

This is a request for additional information regarding an invoice that a vendor has issued to you or your company, where you require additional information before you pay the invoice. The form contains questions concerning details of the goods being sold as well as contact information of you or your company and the vendor.

If you have not registered yet, please register with Tyler Lee Randolph, P.C.

First Name
Middle Initial
Last Name
Address Line 1
Address Line 2 (optional)
Zip Code
How did you find out
about this site?
Create a Username
(at least 6 characters)
Create a Password
Confirm Password
Limited Services Agreement

If you have already created your account with Tyler Lee Randolph, P.C., please log in here.

Forgot your username or password?