| Payment ID | 9432 |
|---|---|
| Date Created | 10/11/22 9:57 am |
| Created By | Gloria Jimenez |
| Service Request | |
| Application ID | 6507 |
| Authorization Number | |
| Applicant Information | |
| Name | EVA SLOVAK |
| Applicant Email Address | Email hidden; Javascript is required. |
| Unique Identifier | 16164000579 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Payment Details | |
| Receipt Amount | $1,086.03 |
| Receipt Date | 10/10/2022 |
| Comments | extended stay at Super 8 departure date is 10/24/2022 |
| Receipt | 10-10-2022SLOVAK1086.03.pdf |
| Staff Name | Gloria Jimenez |
| Case Manager | LRE |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 10/11/2022 |
