| Payment ID | 10823 |
|---|---|
| Date Created | 11/02/22 11:05 am |
| Created By | Gloria Jimenez |
| Service Request | |
| Application ID | 5621 |
| Authorization Number | |
| Applicant Information | |
| Name | Jessica Maddux |
| Applicant Email Address | Email hidden; Javascript is required. |
| Unique Identifier | 16170500517 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Payment Details | |
| Receipt Amount | $32.92 |
| Receipt Date | 10/10/2022 |
| Comments | non cash charge to viking done on 10/10/2022 |
| Staff Name | Gloria Jimenez |
| Case Manager | DG |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 11/02/2022 |
