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Inland Regional Center

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

Master Trust of California

Online Purchase Request

Please fill out form completely.  If you need assistance with the form, contact Trina Boyce at 909-382-4833 or Vanesa Macias at 909-382-4678.

Please note, if some items requested are not available, the remainder of the items will still be ordered. You may resubmit for missing items on a new request form.

Personal Information

Request Date

Date Picker

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

Purchase Information

Total Amount of Purchase

Shipping Information

Shipping Address

For Master Trust Use Only:

Trust #


Approved by:

Purchase Made By:

Date Purchase Made: