| Payment ID | 1680 |
|---|---|
| Date Created | 06/07/22 1:02 pm |
| Created By | Gloria Jimenez |
| Service Request | |
| Application ID | 1208 |
| Authorization Number | |
| Applicant Information | |
| Name | Ronnie White |
| Unique Identifier | 16171200145 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Payment Details | |
| Receipt Amount | $1,561.94 |
| Receipt Date | 06/09/2022 |
| Comments | hotel stay at Woodsprings Ste |
| Staff Name | Deborah Green |
| Staff Signature | |
| Verifier Name | Gloria JImenez |
| Verifier Signature | |
| Date Verified | 06/07/2022 |
