| Payment ID | 94095 |
|---|---|
| Date Created | 02/19/25 12:51 pm |
| Created By | Gloria Jimenez |
| Service Request | 92455 |
| Application ID | 39876 |
| Authorization Number | 225034 |
| Applicant Information | |
| Name | Joyce ross |
| Applicant Email Address | Email hidden; Javascript is required. |
| Unique Identifier | 16170402374 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Type of Service Request | Hotel Stay |
| Location | Delta Inn |
| Start Day | Monday |
| Guests | 1 |
| From | 02/12/2025 |
| To | 02/19/2025 |
| Days | 7 |
| Payment Details | |
| Payment Amount | $289.00 |
| Receipt Amount | $1,156.00 |
| Receipt Date | 02/13/2025 |
| Comments | hotel stay at Delta Inn departure date is 02/21/25 |
| Receipt | |
| Staff Name | Gloria Jimenez |
| Case Manager | BP |
| Case Worker Email | Email hidden; Javascript is required. |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 02/19/2025 |
