FMS Pay — SDP One-Time Purchase Request

The purpose of this form is to document and support the one-time purchase of products/goods identified in the participant's certified spending-plan. Purchases are charged to the company's credit card and reimbursed from the participant's spending-plan. Purchases must support an IPP goal(s). Note: for recurring services (like a monthly gym membership) or registrations that need a card number (like camp or class registration), use our Virtual Card Request instead. Purchase requests should not be used to request payment on a service provider's invoice.

A note about merchants: due to the nature of third-party funding and purchasing, FMS Pay may not be able to purchase from all merchants — some retailers' policies do not accommodate third-party purchases. For example, Costco requires the purchaser to be the member, so we are unable to buy there on your behalf. If we are unable to buy from your requested merchant, we will contact you to identify an alternative merchant for the same or a comparable item.

Is this product/good CLEARLY identified in your certified spending-plan on file?

⚠ If the product or service is not clearly identified in the spending-plan, we will need Regional Center approval from your case manager — no exceptions. Please contact your case manager and attach their written approval below, or email it to connect@fmspay.com. Your purchase cannot be completed until this approval is received.

Regional Center / case manager approval (if item not clearly in spending-plan)

Participant Name

UCI #

Your Regional Center client number (also called UCI). Ask your case manager if you're not sure.

Contact email

example@example.com

Contact phone

Please enter a valid phone number.Format: (000) 000-0000.

Mailing / Shipping Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Would you like to pick this order up in-store instead of shipping?

Pickup person's full name

Must match the ID they'll show at pickup.

Pickup person's phone number

Please enter a valid phone number.Format: (000) 000-0000.

Pickup store location

Specific store address or location, e.g., 'Best Buy — 1880 Marron Rd, Carlsbad, CA 92008'.

Special delivery instructions — when possible

Service Code

e.g., 333 Participant-Directed Goods and Services

Merchant

e.g., Amazon, Best Buy, Target

Item/Product

URL

Direct link to the exact product

Specifics (color, model number, size, etc.)

Quantity & Total Cost

Include estimated tax and shipping — these are charged to the spending-plan.

IPP goal(s) satisfied

Which IPP goal(s) does this purchase support?

Would you like to add another product?

Service Code (Product 2)

Merchant (Product 2)

Item/Product (Product 2)

URL (Product 2)

Specifics (Product 2)

Quantity & Total Cost (Product 2)

IPP goal(s) satisfied (Product 2)

Add a third product?

Service Code (Product 3)

Merchant (Product 3)

Item/Product (Product 3)

URL (Product 3)

Specifics (Product 3)

Quantity & Total Cost (Product 3)

IPP goal(s) satisfied (Product 3)

Add a fourth product?

Service Code (Product 4)

Merchant (Product 4)

Item/Product (Product 4)

URL (Product 4)

Direct link to the exact product

Specifics (Product 4)

Quantity & Total Cost (Product 4)

Include estimated tax and shipping — these are charged to the spending-plan.

IPP goal(s) satisfied (Product 4)

Which IPP goal(s) does this purchase support?

Add a fifth product?

Service Code (Product 5)

Merchant (Product 5)

Item/Product (Product 5)

URL (Product 5)

Direct link to the exact product

Specifics (Product 5)

Quantity & Total Cost (Product 5)

Include estimated tax and shipping — these are charged to the spending-plan.

IPP goal(s) satisfied (Product 5)

Which IPP goal(s) does this purchase support?

Before you sign, please review 'What Can or Cannot be Paid and Why' (Enclosure B) — common items that CANNOT be purchased with SDP funds include: room and board (rent, groceries, meals, hotel stays); entertainment with no therapeutic or physical benefit (amusement park or concert tickets, hobby supplies, TV, cable, DVDs); purchase or lease of a vehicle; vehicle repairs or improvements unrelated to disability needs; and home repairs/renovations of general utility (aesthetic remodels, roofing, plumbing, HVAC, appliances).

In plain words: some things can't be bought with SDP money — like rent, groceries, entertainment tickets, or vehicles. Please check the list before you sign.

Enclosure B review

In plain words: FMS Pay buys the item and your spending-plan pays for it. Most purchases are final — no refunds for changing your mind. FMS Pay buys items directly and cannot pay you back for things you buy yourself. Tax and shipping also come out of your spending-plan.

Participant agreement

I authorize FMS Pay to purchase the referenced product(s) in this purchase request and bill the cost to my spending-plan. FMS Pay does not recommend any specific goods or services, therefore FMS Pay offers no guarantees, warranties, or promises of satisfaction, and I understand that ALL PURCHASES MAY BE FINAL, depending on the merchant's return policies. FMS Pay is not responsible for buyer's remorse or dissatisfaction with the product, and is not responsible if the product is defective, damaged, or does not function as advertised. I understand FMS Pay is not responsible for failures outside the company's control, such as the merchant's failure to deliver, delivery of an incorrect product, or products lost/stolen in the mail or during delivery. I have provided FMS Pay with my correct and valid address; FMS Pay is not responsible for porch pirate thefts. I understand that FMS Pay must purchase all items directly — reimbursements to participants are not permitted under any circumstances — and that taxes and shipping are charged to my spending-plan. I understand FMS Pay cannot guarantee meeting sales deadlines or limited-stock deadlines, and that receipts are retained for audit purposes and stored in my Sync portal. The product(s) in this purchase request satisfy IPP goal(s) and will be used for that purpose.

Participant / Representative Name

Signature

Date Signed

Date

FMS Pay — SDP One-Time Purchase Request

Participant Information

Product 1

Product 2

Product 3

Product 4

Product 5

Participant Agreement