Form FEMA Form 009-0-12 FEMA Form 009-0-12 Force Account Labor Summary Record

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
FORCE ACCOUNT LABOR 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

NAME
JOB TITLE
NAME
JOB TITLE
NAME
JOB TITLE
NAME
JOB TITLE
NAME
JOB TITLE

DATES AND HOURS WORKED EACH WEEK

COSTS
TOTAL
HOURS

DATE

HOURLY
RATE

BENEFIT
RATE/HR

TOTAL
HOURLY
RATE

TOTAL
COSTS

REG.
O.T.
REG.
O.T.
REG.
O.T.
REG.
O.T.

TOTAL COSTS FOR FORCE ACCOUNT LABOR REGULAR TIME

$

TOTAL COST FOR FORCE ACCOUNT LABOR OVERTIME

$

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

TITLE

FEMA Form 009-0-123, (4/10)

PREVIOUS EDITION OBSOLETE

DATE

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.