| Payment ID | 2982 |
|---|---|
| Date Created | 06/24/22 9:40 am |
| Created By | Gloria Jimenez |
| Service Request | |
| Application ID | 2694 |
| Authorization Number | |
| Applicant Information | |
| Name | Ricky Ervin |
| Unique Identifier | 16170700252 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Payment Details | |
| Receipt Amount | $933.80 |
| Receipt Date | 06/24/2022 |
| Comments | Studio 6. this is the amount charged, but the amount quoted to him was $1867.60 |
| Staff Name | Gloria Jimenez |
| Case Manager | AL |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 06/24/2022 |
