| Payment ID | 3688 |
|---|---|
| Date Created | 07/07/22 1:02 pm |
| Created By | Gloria Jimenez |
| Service Request | |
| Application ID | 2868 |
| Authorization Number | |
| Applicant Information | |
| Name | Garrett Coulter |
| Applicant Email Address | Email hidden; Javascript is required. |
| Unique Identifier | 16170600277 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Payment Details | |
| Receipt Amount | $2,370.00 |
| Receipt Date | 06/30/2022 |
| Comments | hotel stay for 30 days at Super 8 starting 7/1/22 |
| Staff Name | Gloria Jimenez |
| Case Manager | DG |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 06/30/2022 |
