Master Trust of California

Disbursement Request

If you need assistance filling out this form, contact Trina Boyce 909-382-4833.

Checks cannot be paid directly to a beneficiary, contact us for more information.

If request is to pay cable, cell phone, pest control, or any other monthly service, bills must be sent to Master Trust of California.

Requests are processed on Wednesday or in case of holiday, checks will be processed the next business day. Some requests require review by the Master Trust committee. If your request is referred to the committee for review, you will be notified.

Personal Information

Request Date

Beneficiary Name

Beneficiary Age

UCI or Account Number

Indicate benefits Beneficiary receives (check all that apply)

Supplemental Security Income (SSI)

Medi-Cal

SSDI

Name of Requester

Relationship to Beneficiary

Requester Phone Number

Requester E-Mail

Purchase Information

Purchase type

Reimbursement of purchase (receipts required)

Future purchase (receipts must be submitted after purchase)

Ongoing purchase (indicate frequency in comments)

Item #1 - Description

Item #1 - Price

Justification

Do you have items to add to this request?

Yes

Item #2 - Description

Item #2 - Price

Justification

Do you have items to add to this request?

Yes

Item #3 - Description

Item #3 - Price

Justification

Comments

Total Requested

Make check payable to:

Check Payable To:

Relationship to Beneficiary

Is this a new address?

Upload File(s)/Receipts

For Master Trust Use Only:

Trust #

Account Balance:

Approved by:

Referred to Commitee?