| Payment ID | 9331 |
|---|---|
| Date Created | 10/06/22 2:54 pm |
| Created By | Gloria Jimenez |
| Service Request | |
| Application ID | 5396 |
| Authorization Number | |
| Applicant Information | |
| Name | Cody Edmonds |
| Applicant Email Address | Email hidden; Javascript is required. |
| Unique Identifier | 16171000498 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Payment Details | |
| Receipt Amount | $378.24 |
| Receipt Date | 10/04/2022 |
| Comments | extended stay at Super 8 departure date is 10/10/22 |
| Receipt | 9331-Edmonds.pdf |
| Staff Name | Gloria Jimenez |
| Case Manager | DG |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 10/06/2022 |
