Form FEMA Form 009-0-12 FEMA Form 009-0-12 Rented Equipment Summary Record

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

PAGE

RENTED EQUIPMENT SUMMARY RECORD
PA ID NO.

APPLICANT
LOCATION/SITE

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

OF

PROJECT NO.

DISASTER

CATEGORY

PERIOD COVERING

DESCRIPTION OF WORK PERFORMED

TYPE OF EQUIPMENT
Indicate size, Capacity, Horsepower
Make and Model as Appropriate

DATES AND
HOURS USED

RATE PER HOUR
W/OPR

W/OUT
OPR

TOTAL
COST

VENDOR

INVOICE NO.

DATE AND
AMOUNT PAID

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

FEMA Form 009-0-125, (4/2010)

TITLE

PREVIOUS EDITION OBSOLETE

DATE

CHECK NO.

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average .5 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.