| Payment ID | 3218 |
|---|---|
| Date Created | 06/28/22 1:34 pm |
| Created By | Gloria Jimenez |
| Service Request | |
| Application ID | 2778 |
| Authorization Number | |
| Applicant Information | |
| Name | heather simpson |
| Unique Identifier | 16170700266 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Payment Details | |
| Receipt Amount | $1,830.00 |
| Receipt Date | 06/28/2022 |
| Comments | hotel stay for 30 days at Red Roof Inn |
| Receipt | 28-06-2022simpson1830.00.pdf |
| Staff Name | Gloria Jimenez |
| Case Manager | DG |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 06/28/2022 |
