[Inland Regional Center] Online Purchase Request

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. Send text to 909-453-5304.

Vanesa Macias - Trust Associate at 909-382-4678 or vmacias@inlandrc.org. Send text to 909-893-1333.

Hazel Harmon - Assistant to the Trust Administrator at 909-890-3427 hharmon@inlandrc.org.

Cheyenne Pedroza - Account Technician at 909-890-3431 or chpedroza@inlandrc.org.

Requests are reviewed weekly. In some cases, the Master Trust Committee may need to review the reqeust. They meet on the second Tuesday of each month. You will be notified if the committee will be reviewing your request.

Please provide as many details about the items you want to purchase. 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

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

Supplemental Security Income (SSI) (SSI is received on the 1st of the month)

Medi-Cal

SSDI (SSA) (SSA is received on the 3rd of the month or on a Wednesday in the month.

Housing subsidy (Section 8 or HUD)

Do you have a payee for your benefits? If yes, please list who your payee is.

Name of Requester

Relationship to Beneficiary

Requester Phone Number

Email address for confirmation

Purchase Information

Merchant Name:

Item #1 - Link

Please provide details about the desired items.

Item #1 - Price

Justification (Reason for the Request)

Do you have additional items to add to this request?

Yes

Merchant Name :

Item #2 - Link

Please provide details about the desired items.

Item #2 - Price

Justification (Reason for the Request)

Merchant Name :

Item #3 - Link

Please provide details about the desired items.

Item #3 - Price

Justification (Reason for the Request)

Additional Items?

Yes

Merchant Name :

Item #4 - Link

Please provide details about the desired items.

Item #4 - Price

Justification (Reason for the Request)

Total Amount of Purchase

Shipping Information

Name

For Master Trust Use Only:

Balance:

Approved by:

Purchase Made By:

Date Purchase Made:

Notes: