1440 Rosecrans Ave.
Manhattan Beach, CA 90266
800.854.9846 • www.kinecta.org
CONSUMER ATM /
DEBIT CARD DISPUTE FORM
RETAILSERVICES
KFCUL18139 - 11/17
SECTION 1
DISPUTE INFO
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.
SECTION 2
MEMBER INFO
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
SECTION 3
TRANSACTION INFO
Please record the transaction(s) that are being disputed as error/fraud/unauthorized in the table below.
All fields below should be completed.
TRANSACTION
DATE
TRANSACTION TYPE
(Example: ATM Withdrawal/Disburse Error, Merchant Purchase, Online Transaction)
DISCOVERY
DATE
TRANSACTION
AMOUNT
SECTION 4
MEMBER’S STATEMENT
To the best of your knowledge, please provide a detailed description of your dispute.
QUESTIONS FOR MEMBER
Status of card?
q
In My Possession
q
Lost
q
Stolen
Do you have any knowledge of who might have conducted the transaction(s) recorded in section 2?
q
YES
q
NO
Have you benefited financially from any of the transactions listed in section 3?
q
YES
q
NO
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
