| Payment ID | 6308 |
|---|---|
| Date Created | 08/22/22 2:44 pm |
| Created By | Gloria Jimenez |
| Service Request | |
| Application ID | 4012 |
| Authorization Number | |
| Applicant Information | |
| Name | Matthew Millsap |
| Applicant Email Address | Email hidden; Javascript is required. |
| Unique Identifier | 16171000379 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Payment Details | |
| Receipt Amount | $1,262.70 |
| Receipt Date | 08/16/2022 |
| Comments | hotel stay at Studio 6 departure date is 9/6/22 |
| Receipt | 6308-Millsap.pdf |
| Staff Name | Gloria Jimenez |
| Case Manager | DG |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 08/22/2022 |
