| Payment ID | 35307 |
|---|---|
| Date Created | 07/27/23 2:03 pm |
| Created By | Gloria Jimenez |
| Service Request | 25000 |
| Application ID | 23296 |
| Authorization Number | |
| Applicant Information | |
| Name | Asha Page |
| Applicant Email Address | Email hidden; Javascript is required. |
| Unique Identifier | 16113401555 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Type of Service Request | Hotel Stay |
| Location | Woodspring Suites |
| Location Contact Name | Everesta |
| Location Email Address | Email hidden; Javascript is required. |
| Start Day | Monday |
| Guests | 4 |
| From | 05/10/2023 |
| To | 05/17/2023 |
| Days | 9 |
| Payment Details | |
| Payment Amount | $1,200.00 |
| Receipt Amount | $469.00 |
| Receipt Date | 07/27/2023 |
| Comments | hotel stay at Extended Stay dates from 07/26/23 departure date is 08/02/23 |
| Receipt | |
| Staff Name | Gloria Jimenez |
| Case Manager | BJ |
| Case Worker Email | Email hidden; Javascript is required. |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 07/27/2023 |
