FSCC/SHARED BRANCH DISPUTE FORM
Name: ___________________________ KeyPoint Credit Union Account Number: _____________________
Address: _____________________________________________________ Apt #: _________________
City: ___________________________________________ State: ___________ Zip: ________________
Daytime Phone Number: _____________________________ Dispute Amount: $ _____________________
Transaction Date: __________________ Service Center Name/Location: _____________________________
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Date
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Date
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UNAUTHORIZED/DISPUTED FUNDS TRANSACTION DECLARATION
You may complete this form online and print to sign and fax or mail as indicated below.
I DECLARE THAT UNDER PENALTY OF PERJURY THAT ALL OF THE INFORMATION SUPPLIED ON THIS
DISPUTE FORM IS TRUE AND CORRECT.
Account Owner Signature
Account Owner Signature
Your signature is required to process this dispute. Please check the appropriate box below and return this
signed form and and any supporting documents, including a copy of the receipt, within ten (10) days so that we
may process your dispute in a timely manner. Attach a separate sheet or letter if more room is needed for your
explanation.
I certify that the joint account owner or myself did not do this transaction.
Transaction was completed for an incorrect amount (please specificy correct amount or provide
documentation. $_____________________
Other (please provide specific details):
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@keypointcu.com OR
Fax To: (408)731-4068 Attn: DISPUTES OR
Mail To: KeyPoint Credit Union
Attn: FSCC DISPUTES
2805 Bowers Avenue
Santa Clara, CA 95051
