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

DEPARTMENT OF HOMELAND SECURITY

PAGE

Federal Emergency Management Agency
FORCE ACCOUNT EQUIPMENT SUMMARY RECORD

OF

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

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.
APPLICANT

PA ID #

LOCATION/SITE

PROJECT #

DISASTER

CATEGORY

PERIOD COVERING

DESCRIPTION OF WORK PERFORMED

TYPE OF EQUIPMENT
INDICATE SIZE, CAPACITY, HOURSEPOWER, MAKE
AND MODEL AS APPROPRIATE

DATES AND HOURS USED EACH DAY
EQUIPMENT
CODE
NUMBER

OPERATOR'S
NAME

DATE

COSTS
TOTAL
HOURS

EQUIPMENT
RATE

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

FEMA Form 009-0-127

TITLE

PREVIOUS EDITION OBSOLETE

DATE

TOTAL
COST