| Payment ID | 2255 |
|---|---|
| Date Created | 06/15/22 9:00 am |
| Created By | Gloria Jimenez |
| Service Request | |
| Application ID | 1206 |
| Authorization Number | |
| Applicant Information | |
| Name | aminah lewis |
| Unique Identifier | 16170600144 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Payment Details | |
| Receipt Amount | $1,940.48 |
| Receipt Date | 06/14/2022 |
| Comments | hotel stay at Comfort Suites for a month |
| Staff Name | Gloria Jimenez |
| Case Manager | AL |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 06/15/2022 |
