| Payment ID | 104000 |
|---|---|
| Date Created | 04/28/25 9:37 am |
| Created By | Gloria Jimenez |
| Service Request | 97910 |
| Application ID | 93249 |
| Authorization Number | 225457 |
| Applicant Information | |
| Name | Bryan Brooks |
| Applicant Email Address | Email hidden; Javascript is required. |
| Unique Identifier | 16170404524 |
| Payment Type | Transportation |
| Type of Service Request | Transportation |
| Payment Details | |
| Payment Amount | $40.00 |
| Receipt Amount | $40.00 |
| Receipt Date | 04/24/2025 |
| Comments | Delivered to Super 8. |
| Receipt | |
| Staff Name | Gloria Jimenez |
| Case Manager | BP |
| Case Worker Email | Email hidden; Javascript is required. |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 04/28/2025 |
