Date: __________

To: ___________________ (Customer)

Reference is made to your order for certain goods under date of ___________, 19____.

We are withholding delivery for the reason[s] checked:

__ Required payment has not been made.

__ You repudiated or withdrew your contract to buy.

__ You failed to furnish requested shipping instructions.

__ Certain goods are back ordered and shipment will be made in single lot.

__ ______________________________________ (other description).

Very truly,

_______________________________