| Payment ID | 107667 |
|---|---|
| Date Created | 05/25/25 1:04 pm |
| Created By | Gloria Jimenez |
| Service Request | 106450 |
| Application ID | 103730 |
| Authorization Number | 225942 |
| Applicant Information | |
| Name | Kenneth Tarver |
| Applicant Email Address | Email hidden; Javascript is required. |
| Unique Identifier | 16171004931 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Type of Service Request | Hotel Stay |
| Location | Delta Inn |
| Start Day | Monday |
| Guests | 1 |
| From | 05/21/2025 |
| To | 05/28/2025 |
| Days | 7 |
| Payment Details | |
| Payment Amount | $450.00 |
| Receipt Amount | $664.70 |
| Receipt Date | 05/16/2025 |
| Comments | hotel stay at Delta Inn |
| Receipt | 107667-Tarver.pdf |
| Staff Name | Gloria Jimenez |
| Case Manager | DJ |
| Case Worker Email | Email hidden; Javascript is required. |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 05/25/2025 |
