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

Public Assistance Program

FEMA Form 009-0-124

Materials Summary Record

OMB: 1660-0017

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DEPARTMENT OF HOMELAND SECURITY

PAGE

Federal Emergency Management Agency
MATERIALS SUMMARY RECORD

O.M.B. NO. 1660-0017
Expires July 31, 2016

OF

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,
500 C Street, SW, Washington, DC 20472-3100, Paperwork Reduction Project (1660-0017). NOTE: Do not send your completed questionnaire to this address.
PA ID #.

APPLICANT
LOCATION/SITE

PROJECT #.

DISASTER

CATEGORY

PERIOD COVERING

DESCRIPTION OF WORK PERFORMED

VENDOR

DESCRIPTION

QUAN.

UNIT
PRICE

TOTAL
PRICE

DATE
PURCHASED

DATE
USED

INFO FROM (CHECK ONE)
INVOICE

GRAND TOTAL
CERTIFIED

FEMA Form 009-0-124

TITLE

PREVIOUS EDITION OBSOLETE

DATE

STOCK


File Typeapplication/pdf
File TitleSpecial Consideration Questions
File Modified2014-05-05
File Created2014-05-05

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