Form FEMA Form 009-0-12 FEMA Form 009-0-12 Materials Summary Record

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
MATERIALS SUMMARY RECORD
PA ID NO.

APPLICANT
LOCATION/SITE

PAGE

O.M.B. No. 1660-0017
Expires April 30, 2013

OF

PROJECT NO.

DISASTER

CATEGORY

PERIOD COVERING

DESCRIPTION OF WORK PERFORMED

VENDOR

DESCRIPTION

QUAN.

UNIT
PRICE

TOTAL
PRICE

DATE
PURCHASED

DATE
USED

INFO FROM
(CHECK ONE)
INVOICE STOCK

GRAND TOTAL
I CERTIFY THAT THE INFORMATION WAS OBTAINED FROM PAYROLL RECORDS, INVOCIES, OR OTHER DOCUMENTS THAT ARE AVAILABLE FOR AUDIT.
CERTIFIED

FEMA Form 009-0-124, (4/10)

TITLE

PREVIOUS EDITION OBSOLETE

DATE

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average .25 hours per response. The burden estimates includes time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and submitting this form. You are not required to respond to this collection of information unless a valid OMB control
number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management,
Department of Homeland Security, Federal Emergency Management Agency, 1800 South Bell Street, Arlington, VA 20598-3005, Paperwork Reduction Project (1660-0017). NOTE: Do
not send your completed questionnaire to this address.