| Payment ID | 16219 |
|---|---|
| Date Created | 01/27/23 11:37 am |
| Created By | Gloria Jimenez |
| Service Request | |
| Application ID | 14567 |
| Authorization Number | |
| Applicant Information | |
| Name | Crystal Lewis |
| Applicant Email Address | Email hidden; Javascript is required. |
| Unique Identifier | 16170601115 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Payment Details | |
| Payment Amount | $544.68 |
| Receipt Amount | $544.68 |
| Receipt Date | 01/26/2023 |
| Comments | hotel stay at Super 8 departure date is 02/01/23 |
| Receipt | 26-01-2023Lewis544.68.pdf |
| Staff Name | Gloria Jimenez |
| Case Manager | AL |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 01/27/2023 |
