| Payment ID | 15353 |
|---|---|
| Date Created | 01/11/23 12:39 pm |
| Created By | Gloria Jimenez |
| Service Request | |
| Application ID | 14373 |
| Authorization Number | |
| Applicant Information | |
| Name | Darmon Forward |
| Agency Name | Veterans Administration |
| Agency Code | 220308 |
| Agency | Veterans Administration |
| Agency Email Address | Email hidden; Javascript is required. |
| Applicant Email Address | Email hidden; Javascript is required. |
| Unique Identifier | 16170401086 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Payment Details | |
| Payment Amount | $1,200.00 |
| Bank Fees | No |
| Receipt Amount | $1,200.00 |
| Receipt Date | 01/10/2023 |
| Comments | hotel stay at Studio 6 departure date is 01/24/23 |
| Receipt | 10-01-2023Forward1200.00.pdf |
| Staff Name | Gloria Jimenez |
| Case Manager | AL |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 01/11/2023 |
