| Payment ID | 10250 |
|---|---|
| Date Created | 10/25/22 3:35 pm |
| Created By | Gloria Jimenez |
| Service Request | |
| Application ID | 2654 |
| Authorization Number | |
| Applicant Information | |
| Name | Jacqueline Moore |
| Applicant Email Address | Email hidden; Javascript is required. |
| Unique Identifier | 16171000248 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Payment Details | |
| Receipt Amount | $456.54 |
| Receipt Date | 10/24/2022 |
| Comments | extended stay at Woodsprings departure date is 10/31/22 |
| Receipt | 10250-Moore.pdf |
| Staff Name | Gloria Jimenez |
| Case Manager | DG |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 10/25/2022 |
