[Inland Regional Center] True Link Disbursement Request

Master Trust of California

Request to Fund True-Link Debit Card

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

Trina Boyce – Senior Trust Associate at 909-382-4833

Vanesa Macias - Trust Associate at 909-382-4678

Cheyenne Dixon - Account Technician at 909-

Hazel Harmon - Account Technician, at 909-890-3427

TrueLink card requests are reviewed and processed each Thursday with funds available next business day. Receipts for purchases or services must be submitted to Master Trust after purchases are made with the TrueLink card. Failure to submit receipts may result in suspension of TrueLink card.

New User

Yes

If you responded yes above please click this link and complete the form prior to submitting this form.

[Inland Regional Center] True Link User Agreement - Revised (seamlessdocs.com)

Personal Information

Request Date

Beneficiary (Consumer) Name

UCI Number or Account Number

Beneficiary (Consumer) Age

Current benefits received, check all that apply:

Supplemental Security Income (SSI)

Medi-Cal

SSDI

Name of Requester

Relationship to Beneficiary (Consumer)

Email address for confirmation

Phone Number

Request Information

Amount Requested

Justification

Store(s) you will be shopping in.

I understand I must submit receipts after purchases are made or future requests may be rejected.

Yes

I understand that I cannot withdraw cash or use the card with a PIN number.

Yes

I understand that I cannot buy groceries or food with the debit card.

Yes

For Master Trust Use Only:

Account Balance:

Approved by:

Funded by:

Date Funded:

Notes: