1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.9846 • www.kinecta.org
CONSUMER ATM /
DEBIT CARD DISPUTE FORM
KFCUL18139 - 11/17
This form may be used to file an ATM / Debit Card dispute on transaction(s) caused by error, fraud, or unauthorized activity. This
dispute form can be faxed or mailed directly to our ATM / Debit Dispute department at fax number 310.727.8221 or mailed to
Risk Operations CU76 c/o Kinecta Federal Credit Union 1440 Rosecrans Avenue, Manhattan Beach, CA 90266. If you have any
questions regarding the status of this dispute, you may contact us at 800.854.9846.
NOTE: If additional space is needed for section 2, 3 and/or 4 below, please include additional sheet with membership
number, date and signature.
NAME (FIRST, MIDDLE, LAST) JR/SR MEMBERSHIP # SHARE ID(S)
ADDRESS (STREET, CITY, STATE, ZIP)
WORK PHONE HOME / CELL PHONE: LAST 4 DIGITS OF CARD
Please record the transaction(s) that are being disputed as error/fraud/unauthorized in the table below.
All fields below should be completed.
(Example: ATM Withdrawal/Disburse Error, Merchant Purchase, Online Transaction)
To the best of your knowledge, please provide a detailed description of your dispute.
QUESTIONS FOR MEMBER
Status of card?
In My Possession
Do you have any knowledge of who might have conducted the transaction(s) recorded in section 2?
Have you benefited financially from any of the transactions listed in section 3?
MEMBER’S SIGNATURE (I affirm that the information furnished above is true to the best of my knowledge.) DATE OF DISPUTE
CREDIT UNION USE ONLY
SERVICE CENTER # TELLER # DAT E REQUEST RECEIVED BY
q In Person q Phone q Fax