Fillable Cardholder Dispute Form (Kinecta)

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Cardholder Dispute Form (Kinecta)

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The Cardholder Dispute Form (Kinecta) form is 2 pages long and contains:

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  • 13 check-boxes
  • 50 other fields

Country of origin: US
File type: PDF

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1440 Rosecrans Avenue, Manhattan Beach, CA 90266
800.268.1884, option 4 | kinecta.org
1 of 2 25353-09/20
ONCE COMPLETED, PLEASE EMAIL ALL PAGES OF THIS FORM TO: RISK_EMAIL@COOP.ORG
Kinecta Credit Card # Cardholder Name
Cardholder Phone # Disputed Amount $ Post Date
Merchant Name
Disputing More Than One Item? Yes No
If Yes, then this is number _____ of _____ (E.G. 1 of 3)
Only One Transaction Per Form
Email Address
Signature Required __________________________________________________________________________________________________
BEFORE DISPUTING CHARGE, YOU MUST MAKE EVERY EFFORT TO RESOLVE THE DISPUTE WITH THE MERCHANT
Select Type of Dispute (Check ONLY one)
Did not recognize - Please attempt to contact the merchant prior to disputing the charge.
• When did the Cardholder contact the Merchant (mm/dd/yy) _____ / _____ / _____
• What was the outcome of the merchant contact? ____________________________________________________________________
I was billed twice for a single purchase - Cardholder certifies one transaction is valid, but it posted more than once.
All cards issued to me are in my possession.
• Valid Transaction $ ___________________________________ Post Date _____________________________________________
• Invalid Transaction $ __________________________________ Post Date _____________________________________________
Membership Cancellation - Please enclose copy of letter, email, or fax informing the merchant of cancellation.
• When did the cardholder contact the merchant? _____________________________________________________________________
• Reason for cancellation? __________________________________________________________________________________________
• Date of cancellation Cancellation # ________________________________________________________________________________
• Were you advised of a cancellation policy? Yes No
If yes, what were you told? __________________________________________________________________________________________
Merchandise was returned - You must attempt to return the merchandise prior to exercising the right. Please attach
signed proof of return or credit slip.
• What was ordered? _______________________________________________________________________________________________
• What was received? ______________________________________________________________________________________________
• Reason for returning _____________________________________________________________________________________________
• Was merchandise suitable for the purpose intended? _________________________________________________________________
• Merchant’s response______________________________________________________________________________________________
Cardholder Dispute Form
1440 Rosecrans Avenue, Manhattan Beach, CA 90266
800.268.1884, option 4 | kinecta.org
2 of 2
ONCE COMPLETED, PLEASE EMAIL ALL PAGES OF THIS FORM TO: RISK_EMAIL@COOP.ORG
I did not receive the merchandise - Please contact the merchant and notify us of the outcome.
• When did the cardholder contact the merchant?_____________________________________________________________________
• What was the outcome of the merchant contact? ____________________________________________________________________
• What was the expected delivery date? _____ / _____ / _____ Pickup date? _____ / _____ / _____
• What was the merchandise that was ordered? _______________________________________________________________________
I was overcharged for the purchase - Please include a copy of the signed sales receipt.
My credit posted as a sale - Please attach a copy of the credit slip and the original sales slip.
The credit did not post to my account - Please enclose a copy of the dated credit slip or notice of credit from the merchant
and a detailed explanation of your dispute.
I paid by other means - You must provide proof of payment by other means such as a copy of the cancelled check (front and
back), a cash receipt, or a billing statement from another credit card.
• When did the cardholder contact the merchant?_____________________________________________________________________
• What was the outcome of the merchant contact? ____________________________________________________________________
I was charged for a hotel room, which I cancelled - Cancellation number is required.
• Were you advised of a cancellation policy? Yes No
• If Yes, what was the policy? _______________________________________________________________________________________
• Cancellation number _________________________________ (REQUIRED) Cancel date _____ / _____ / _____
• Copy of phone bill showing you contacted the merchant to cancel.
Service Dispute - Please describe the nature of your dispute and your attempt(s) at resolution on a separate sheet of paper
and attach to this form. Include copies of second opinions from a certified merchant on their invoice or letterhead, repair bills,
contracts or other supporting documentation.
I did not authorize this charge - I certify that I did not authorize or participate in this transaction with the abovementioned
merchant, nor did I authorize anyone else to use my card. To use this option, you must report your card lost or stolen. If you
have not, please call 877.881.6023 before sending in this form.
• If this was for a hotel room, did you request a reservation? No Yes
If Yes, this is not an unauthorized charge. You must call the merchant and attempt to resolve the dispute. If you received a
cancellation number for a reservation, please see the dispute reasons above.
Other - Please enclose a DETAILED description on a SEPARATE SHEET and attach it to this form.
Cardholder Dispute Form
25353-09/20
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Cardholder Dispute Form (Kinecta)

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Completed 25 March 2021

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