Inland Regional Center

info@inlandrc.org

1365 S. Waterman Ave., San Bernardino, CA, 92408, US

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Master Trust of California

Online Purchase Request

Please fill out form completely. If you need assistance with the form, contact:

Trina Boyce – Senior Trust Associate at 909-382-4833 or tboyce@inlandrc.org

Vanesa Macias - Trust Associate at 909-382-4678 or vmacias@inlandrc.org

Requests are reviewed weekly. If some items requested are not available, the remainder of the items will still be ordered. You may submit a new request form for any missing items.

Personal Information

Request Date

Beneficiary (Consumer) Name

UCI or Account Number

Beneficiary Age

Indicate the type of benefits beneficiary receives (check all that apply)

Supplemental Security Income (SSI)

Medi-Cal

SSDI (SSA)

Housing subsidy (Section 8 or HUD)

Name of Requester

Relationship to Beneficiary

Requester Phone Number

Email address for confirmation

Purchase Information

Merchant Name:

Item #1 - Link

Item #1 - Price

Justification

Do you have additional items to add to this request?

Yes

Merchant Name :

Item #2 - Link

Item #2 - Price

Justification

Merchant Name :

Item #3 - Link

Item #3 - Price

Justification

Additional Items?

Yes

Merchant Name :

Item #4 - Link

Item #4 - Price

Justification

Merchant Name :

Item #5 - Link

Item #5 - Price

Justification

Total Amount of Purchase

Shipping Information

Name

Relationship to beneficiary

For Master Trust Use Only:

Balance:

Approved by:

Purchase Made By:

Date Purchase Made:

Notes: