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

DEPARTMENT OF HOMELAND SECURITY

PAGE

Federal Emergency Management Agency
RENTED EQUIPMENT 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

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

TITLE

PREVIOUS EDITION OBSOLETE

DATE

CHECK NO.