| Payment ID | 9576 |
|---|---|
| Date Created | 10/12/22 5:05 pm |
| Created By | Gloria Jimenez |
| Service Request | |
| Application ID | 3485 |
| Authorization Number | |
| Applicant Information | |
| Name | Stacey Attkisson |
| Applicant Email Address | Email hidden; Javascript is required. |
| Unique Identifier | 11064500330 |
| Payment Type | Short-Term Hotel/Motel Stays |
| Payment Details | |
| Receipt Amount | $171.00 |
| Receipt Date | 10/03/2022 |
| Comments | extended stay at hotel paid on 10/03/2022 |
| Receipt | 11064500330-171.00-03-10-2022.pdf |
| Staff Name | Gloria Jimenez |
| Case Manager | DG |
| Verifier Name | Gloria Jimenez |
| Verifier Signature | |
| Date Verified | 10/12/2022 |
