Master Trust of California

Online Purchase Request

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

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

Serving beneficiaries, last name starting with A-L, Vanesa Macias, Account Technician, at 909-382-4678

Serving beneficiaries, last name starting with M-Z, Hazel Harmon, Account Technician, at 909-890-3427

Requests are reviewed weekly. If some items requested are not available, the remainder of the items will still be ordered. You may submit a new request form for any missing items.

Personal Information

Request Date

Beneficiary (Consumer) Name

UCI or Account Number

Beneficiary Age

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

Supplemental Security Income (SSI)

Medi-Cal

SSDI (SSA)

Name of Requester

Relationship to Beneficiary

Requester Phone Number

Email address for confirmation

Purchase Information

Merchant Name:

Item #1 - Link

Item #1 - Price

Justification

Do you have additional items to add to this request?

Yes

Merchant Name :

Item #2 - Link

Item #2 - Price

Justification

Merchant Name :

Item #3 - Link

Item #3 - Price

Justification

Additional Items?

Yes

Merchant Name :

Item #4 - Link

Item #4 - Price

Justification

Merchant Name :

Item #5 - Link

Item #5 - Price

Justification

Total Amount of Purchase

Shipping Information

Name

Relationship to beneficiary

For Master Trust Use Only:

Balance:

Approved by:

Purchase Made By:

Date Purchase Made:

Notes: