| Payment ID | 5099 |
|---|---|
| Date Created | 08/03/22 10:12 am |
| Created By | Gloria Jimenez |
| Service Request | |
| Application ID | 3412 |
| Authorization Number | |
| Applicant Information | |
| Name | Carol America |
| Applicant Email Address | Email hidden; Javascript is required. |
| Unique Identifier | 16170500323 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Payment Details | |
| Receipt Amount | $675.00 |
| Receipt Date | 07/22/2022 |
| Comments | 2 week stay at Delta Inn |
| Receipt | 5099-America.pdf |
| Staff Name | Gloria Jimenez |
| Case Manager | BP |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 08/03/2022 |
