Form FEMA Form 009-0-12 FEMA Form 009-0-12 Contract Work Summary Record

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
CONTRACT WORK SUMMARY RECORD

PAGE

DATE

PA ID NO.

LOCATION/SITE

CATEGORY

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

OF

PROJECT NO.

DISASTER

PERIOD COVERING

DESCRIPTION OF WORK PERFORMED

DATES WORKED

CONTRACTOR

BILLING/INVOICE
NUMBER

AMOUNT

COMMENTS- SCOPE

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

FEMA Form 009-0-126, (4/2010)

TITLE

PREVIOUS EDITION OBSOLETE

DATE

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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.