Fillable FORM A: Cardholder Dispute Form (KeyPoint Credit Union)

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FORM A: Cardholder Dispute Form (KeyPoint Credit Union)

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The FORM A: Cardholder Dispute Form (KeyPoint Credit Union) form is 4 pages long and contains:

  • 0 signatures
  • 50 check-boxes
  • 125 other fields

Country of origin: US
File type: PDF

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Name
I DECLARE UNDER PENALTY OF PERJURY THAT ALL OF THE INFORMATION SUPPLIED ON THIS DISPUTE FORM
IS TRUE AND CORRECT.
Cancellation dispute:
I cancelled this recurring transaction with the merchant on (Date):
Additional Information is required from merchant to identify the transaction. Not to be used if transaction is confirmed
fraudulent.
Transaction not recognized by cardholder
Daytime Phone Number
KeyPoint CU Account Number (Last four digits only): VISA Card Number (Last four digits only):
Dispute Amount $Transaction Amount $
Merchant Name
Transaction Date
For additional transaction disputes, please fill out FORM B and attach.
Cardholder Dispute Form
_______________________________________________________________ _____________________________
Cardholder/Account Owner Signature Date
_______________________________________________________________ _____________________________
Cardholder/Account Owner Signature
Date
FORM A
UNAUTHORIZED / DISPUTED ELECTRONIC FUNDS TRANSACTIONS DECLARATION
Please check the appropriate box below that matches your dispute type the closest. Your signature above is required.
Return this form and any supporting documents within 10 days so that your dispute can be processed in a timely manner. Please
answer all appropriate questions below. The required fields per dispute type are marked with an asterisk (*). Attach a
separate sheet or letter if more room is needed for your explanation. If any of the below does not accurately reflect your dispute,
please write a separate letter and include all of the transaction information listed above.
Were you advised of any cancellation policy? Yes No (if yes, explain below)
*Date of Cancellation:
Spoke with:
Cancellation number:
Reason:
*Reason for return:
Returned Merchandise Dispute:
*Date Returned: Date Received by Merchant:
If mailed, Return Merchandise Authorization Number (RMA):
*Shipping Company:
Tracking Number:
If you have a Credit Slip/Voucher or a Refund Acknowledgement that has not been posted, please provide:
Date of Credit Slip: Invoice/Receipt Number of the Credit:
*Describe your attempt to resolve with the merchant:
Did the merchant refuse to accept returned merchandise or provide a return authorization?
*Describe your attempt to resolve with the merchant:
How
Check one:
Merchant refused to provide return authorization
Merchant refused to accept returned merchandise
Merchant informed cardholder not to return the merchandise
*Describe your attempt to resolve with the merchant:
I paid for these goods or services by other means:
Check Cash Other Bank Card Other
Note: If selecting this dispute reason, you must supply a copy of proof of payment. Proof can include another Bank Card
statement, copy of the front and back of a canceled check or a cash receipt.
*Describe your attempt to resolve with the merchant:
Non-receipt of goods or services:
*I expected delivery/services on (date):
*Merchant unwilling or unable to provide service.
*Describe your attempt to resolve with the merchant:
Yes
* Merchant Response:
Select One:
Merchandise not received Service not Received
Describe in detail what service or merchandise was ordered:
No (if yes, explain)
A credit for $ was posted to my account as a debit.
A credit transaction posted as a debit in error:
You must supply a copy of the credit receipt received from the merchant.
*The amount of this transaction posted for $ should have posted for $
*Describe your attempt to resolve with the merchant:
Quality of services or goods, defective merchandise or not as described:
*Describe the different between what was ordered and what was received or provide a copy of the written purchase
order. What was defective or why was the purchase unsuitable for your needs?:
*Date merchandise returned: Date received by merchant:
If mailed, Return Merchandise Authorization Number:
Tracking Number:*Shipping Company:
If you have a Credit Slip/Voucher or a Refund Acknowledgement that has not been posted, please provide:
*Describe your attempt to resolve with the merchant
Select One:
service was defective or not as describedMerchandise was defective or not as described
*Date cardholder received merch. or service:
Check one:
Merchant informed cardholder not to return the merchandise
Merchant refused to accept return merchandise
Merchant refused to provide return authorization
*Date services cancelled:
How?
Did the merchant refuse to accept returned merchandise or provide a return authorization?
* If no merchant response, explain:
*Describe your attempt to resolve with the merchant:
Incorrect Transaction Amount:
I did not receive cash from an ATM withdrawal attempt but was charged as if I did receive it:
Transaction reference number:
Other
I made multiple attempts and only received cash on one of those attempts.
I made a single attempt and did not receive cash.
I was charged two or more times for the same transaction:
Date of First Charge:
Date of Second Charge:
Date of Third Charge: Date of Fourth Charge:
*Describe your attempt to resolve with the merchant:
Transaction reference number:
I made a single attempt to load $ and did not receive the funds.
Cardholder participated in the transaction, but did not receive the funds or did not receive the correct amount of
funds.(Dispute amount limited to the amounts of funds not received)
I made a single attempt to load $ and received a partial amount of $
Shared Deposit, performed but not processed, or processed incorrectly:
Did not receive correct amount of funds.
Did not receive funds
Date of Transaction:
Shared Deposit, no document received for deposit return item:
Issuer did not receive returned item documentation within 10 calendar days of returned item Adjustment transaction date.
Transaction reference number: Date of Transaction:
Shared Deposit, Invalid Adjustment
A Shared Deposit Adjustment is disputed by the Cardholder or Issuer.
Please provide details for the check box below:
Adjustment contains invalid data such as:
• Incorrect account number
• Non-matching account number
Cardholder disputes validity of Adjustment due to the amount of the Adjustment, or original Transaction was cancelled
and reversed
Adjustment processed beyond 45 days from Transaction Date
Adjustment processed more than once
Only completed and signed forms will be processed. Signatures must be by the member whose card was involved with the
dispute. Upon completion of this form, please send it to us by one of the following options:
Email To: DisputeForm@kpcu.com OR
Fax To: (408)731-4008 Attn: DISPUTES OR
Mail To: KeyPoint Credit Union
Attn: DISPUTES
2805 Bowers Avenue, Santa Clara, CA 95051
For KeyPoint Credit Union use only: Account was statused on
Check one:
L - Lost N - Not ReceivedS - Stolen X - Counterfeit F - Other Fraud
Additional Information: Please use an additional sheet of paper, if necessary.
*(asterisk) Denotes required information for the dispute
FRAUDULENT TRANSACTION DISPUTE FORM
Name:
I certify that my Visa card was:
VISA Card Number (Last four digits only):
1. Date:
Amount: Merchant:
Merchant:Amount:
2. Date:
Merchant:Amount:
3. Date:
Merchant:Amount:
4. Date:
Merchant:Amount:
5. Date:
6. Date:
Amount: Merchant:
Merchant:Amount:
7. Date:
Merchant:Amount:
8. Date:
Merchant:Amount:
9. Date:
Merchant:Amount:
10. Date:
11. Date:
Amount: Merchant:
Merchant:Amount:
12. Date:
Merchant:Amount:
13. Date:
Merchant:Amount:
14. Date:
Merchant:Amount:
15. Date:
In the event additional charges are identified subsequent to the completion of this affirmation, I authorize my bank to add
those subsequent transactions to this affirmation.
I certify that I did not use and that I did not authorize anyone else to use my card for the Disputed Transactions identified
above. I also certify that I did not receive any value or benefit in connection with the Disputed Transactions. I have made
available above all information and suspicions I have about the Disputed Transactions, including any information regarding
the identity of the person who wrongfully used my card for the Disputed Transactions. I authorize you to share the above
information with law enforcement, banking regulators and other third parties in connection with any investigation of the
Disputed Transactions, including any criminal investigation. I agree to cooperate in any such investigation and in the
prosecution of any person believed to be responsible for fraudulently using my card.
I certify that the information in this Fraudulent Transaction Dispute Form is true and correct.
_______________________________________________________________ _____________________________
Cardholders Signature
As the issuer of this card we certify that our cardholder neither participated in nor authorized the referenced transaction(s).
In addition we certify the following information: Issuer certifies account was closed ___/___/___ Issuer certifies fraud
was reported on DPS VROL ___/___/___. Issuer certifies account was placed on the Exception File, with a pickup code on
___/___/___. Issuer certifies dispute was received via their Online Secure Banking Environment (if applicable) and that unique
identity represents the cardholder's signature.
Date
KeyPoint Account Operations Department use only:
Lost (0)
Stolen (1)
Card not received (2)
Counterfeit, card present (4)
Card still in my possession (6)
and the following transactions were not made by me or anyone authorized to use my Visa card.
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FORM A: Cardholder Dispute Form (KeyPoint Credit Union)

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Completed 18 June 2021

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