| Payment ID | 5113 |
|---|---|
| Date Created | 08/03/22 10:53 am |
| Created By | Gloria Jimenez |
| Service Request | |
| Application ID | 3711 |
| Authorization Number | |
| Applicant Information | |
| Name | Rosemary Rios |
| Applicant Email Address | Email hidden; Javascript is required. |
| Unique Identifier | 16170800351 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Payment Details | |
| Receipt Amount | $1,974.00 |
| Receipt Date | 08/01/2022 |
| Comments | hotel stay at Studio 6 for 30 days departure date is 8/31/2022 |
| Receipt | 5113-Rios.pdf |
| Staff Name | Gloria Jimenez |
| Case Manager | AL |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 08/03/2022 |
