[Inland Regional Center] True Link Disbursement Request

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. or tboyce@inlandrc.org. Text to 909-453-5304.

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

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

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

TrueLink card requests are reviewed and processed each Tuesday 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.

Some reqeusts require review by the Master Trust Committee. The committee meets on the second Tuesday of each month. If your request needs to be reviewed by the committee, you will be notified.

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

Current benefits received, check all that apply:

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

Medi-Cal

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

Housing Subsidy, aka HUD Housing

Other

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

Name of Requester

Relationship to Beneficiary (Consumer)

Email address for confirmation

Phone Number

Request Information

Amount Requested

Justification (Reason for Request)

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 or use as a debit card.

Yes

For Master Trust Use Only:

Account Balance:

Approved by:

Funded by:

Date Funded:

Notes: