| Payment ID | 5580 |
|---|---|
| Date Created | 08/12/22 8:48 am |
| Created By | Gloria Jimenez |
| Service Request | |
| Application ID | 5022 |
| Authorization Number | |
| Applicant Information | |
| Name | Cecil Roach |
| Applicant Email Address | Email hidden; Javascript is required. |
| Unique Identifier | 16170500458 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Payment Details | |
| Receipt Amount | $1,125.00 |
| Receipt Date | 08/04/2022 |
| Comments | hotel stay at the Delta Inn starting 8/4/2022 departure date is 9/4/2022 |
| Receipt | 5580-Roach.pdf |
| Staff Name | Gloria Jimenez |
| Case Manager | CC |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 08/12/2022 |
