Purchase Request Form

Purchase Request
Date*

MonthDayYear
Date
Name of participant*

First NameLast Name
UCI #*
Regional Center *
Name of Person Filling Out This Form*

First NameLast Name
Email Address of Person Filling Out This Form *
example@example.com
Phone Number of Person Filling Out This Form*
Please enter a valid phone number.
What Item or Service is Being Purchased From the Spending Plan? (This Must Be Listed on the Spending Plan)*
Type of Purchase?*
What Business or Store Will Receive the Payment?*
(e.g., Costco, Amazon, Walmart)
Service Code (From the Spending Plan)*
What is the Total Cost for the Good/Item or Service as Stated on Your Spending Plan?*
Provide Any Additional Information (Optional)
Check this Box to Receive a Copy of this Purchase Request with Your Virtual Credit Card
Terms of Purchase

All purchases are required to be made with a virtual credit card, unless prior approval is granted to pay by check.
Purpose & Timing*

I acknowledge that the requested goods or services support the participant’s IPP goals and that it may take up to 30 business days for this purchase to be completed.
Credit Card Use & Responsibility*

I agree to use the virtual credit card only for the approved product or service listed on this request, up to the approved total cost. If services discontinue and I do not inform Arch FMS, I understand that unapproved use may result in me being responsible for any charges.
Final Sale & Limitations*

I understand that all purchases are final and that Arch FMS is not responsible for refunds, delivery issues, incorrect items, or loss or theft during shipping or delivery.
Signature*

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Purchase Request

Terms of Purchase