| Payment ID | 1675 |
|---|---|
| Date Created | 06/07/22 12:46 pm |
| Created By | Gloria Jimenez |
| Service Request | |
| Application ID | 209 |
| Authorization Number | |
| Applicant Information | |
| Name | Lawrence Bisby |
| Unique Identifier | 11064500022 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Payment Details | |
| Receipt Amount | $1,740.20 |
| Receipt Date | 06/05/2022 |
| Comments | hotel stay to Super 8 |
| Receipt | 05-06-2022Bisby1740.20.pdf |
| Staff Name | Deborah Green |
| Staff Signature | |
| Verifier Name | Gloria JImenez |
| Verifier Signature | |
| Date Verified | 06/07/2022 |
