[Your letterhead, if desired; if not, your return address]

[Date of letter-month, day, and year]

[Recipient's first and last names]
[Company name]
[Street or P.O. box address]
[City, State ZIP code]

Dear [recipient's name]:

I am enclosing with this letter a check for $67.25, which is a payment on the amount owed to your company for account number 2943783.

Please send me a written confirmation, notifying me that you have received this payment and have applied it toward the total owed. I will continue to make monthly payments according to the terms on which we agreed.

Thank you for your prompt attention to this matter.

Sincerely,

[Signature]

[Sender's first and last names]