[Inland Regional Center] Disbursement Request

Disbursement Request

Checks cannot be paid directly to a beneficiary. If request is to pay cable, pest control, cell phone, or any other monthly service, bills must be sent directly to our offices.

If you need assistance with this form, please 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 hharmon@inlandrc.org or 909-890-3427.

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

Requests are processed on Tuesdays, or in case of holiday, checks will be processed the next business day. Some requests require review by the Master Trust committee. The Master Trust Committee meets on the second Tuesday of each month. If your request is referred to the committee for review, you will be notified.

Personal Information

Request Date

Beneficiary (Consumer) Name

UCI or Account Number

Indicate 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

Requester E-Mail

Make check payable to:

Check Payable To:

Upload File(s)/Receipts

Click Here to Upload

For Master Trust Use Only:

Set Review Date For:

Account Balance:

Approved by:

Referred to Committee?

Disbursement Request

Personal Information

Purchase Information

Make check payable to: