Form FEMA Form 112-0-4 FEMA Form 112-0-4 Outlay Report and Request for Reimbursement for Construc

O.M.B. No. 1660-0025 Expires November 30 2013

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

OUTLAY REPORT AND REQUEST FOR
REIMBURSEMENT FOR CONSTRUCTION PROGRAMS
3. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL ELEMENT TO
WHICH THIS REPORT IS SUBMITTED

6. EMPLOYER IDENTIFICATION

7. RECIPIENT ACCOUNT OR OTHER
IDENTIFYING NUMBER

PAGE

OF

2. BASIS OF REQUEST
Cash
Accrual

PAGES

1. TYPE OF REQUEST
Final
Partial
4. FEDERAL GRANT OR OTHER
IDENTIFYING NO. ASSIGNED BY FEMA

5. PARTIAL PAYMENT
REQUEST NO.

8. PERIOD COVERED BY THIS REPORT
FROM (Month, day, year)

TO (Month, day, year)

9. NAME (Recipient Organization)

10. PAYEE (Where checks should be sent if different than item 9)

ADDRESS (City, State and Zip Code)

ADDRESS (City, State and Zip Code)

11. STATUS OF FUNDS
CLASSIFICATION
a. Administrative expense

PROGRAMS-FUNCTIONS-ACTIVITIES
(a)

(b)

$

$

TOTAL
$

b. Preliminary expense
c. Land, structures, right-of-way
d. Architectural engineering basic fees
e. Other architectural engineering fees
f. Project inspection fees
g. Land development
h. Relocation expense
i. Relocation payments to individuals and businesses
j. Demolition and removal
k. Construction and project improvement cost
l. Equipment
m. Miscellaneous cost
n. Total cumulative to date (sum of lines a thru m)
o. Deductions for program income
p. Net cumulative to date (line n minus line o)
q. Federal share to date
r. Rehabilitation grants (100% reimbursement)
s. Total Federal share (sum of lines q and r)
t. Federal payments previously requested
u. Amount requested for reimbursement
v. Percentage of physical completion of project

12. CERTIFICATION
I certify that to the best of my knowledge and belief the
billed costs or disbursements are in accordance with the terms
of the project and that the reimbursement represents the
Federal share due which has not been previously requested
and that an inspection has been performed and all work is in
accordance with the terms of the award.

FEMA Form 112-0-4 (11/2010)

a.
Recipient

Signature of Authorized Certifying
Official

Date Report Submitted

Typed or Printed Name And Title

Telephone (Area Code, Number, &
extension)

Signature of Authorized Certifying
Official

Date Signed

b.
Representative
Typed or Printed Name And Title
Certifying To
Official
Line 11.v.

PREVIOUS EDITION OBSOLETE

Telephone (Area Code, Number, &
Extension)

Paperwork Burden Disclosure Notice
Public reporting burden for this form is estimated to average 17.2 hours per response. The burden estimate includes the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing, and submitting the form. This
collection of information is required to obtain or retain benefits. You are not required to submit to this collection of information unless it
displays a valid OMB control number. 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, and Paperwork Reduction Project (1660-0025). NOTE: Do not send your completed form to this
address.

INSTRUCTIONS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11a.
11b.
11c.
11d.
11e.
11f.
11h.
11i.
11j.
11k.
11l.
11m.
11n.
11o.
11p.
11q.
11r.
11t.
11u.
11v.

Mark the appropriate box.
Mark the appropriate box.
Enter the name of the FEMA Regional Office which awarded the grant/cooperative agreement to your organization.
Enter the number assigned by FEMA. This number can be found in item 1 of the Obligating Document for Award/Amendment,
FEMA Form 76-10A.
This item will not be used to report in the EOC program.
Enter the number assigned by the Internal Revenue Service. This number should be the same number reported in item 6
of the applicant's Application for Federal Assistance, SF 424.
This space is reserved for an account number or other identifying number assigned by the recipient.
Enter the beginning and
ending dates of the quarter you are reporting on.
Enter the name and address of the organization receiving the grant. This
information should be the same information as shown in item 5 of FEMA Form 76-10A.
Enter where checks should be sent if different than item 9.
Enter amount expended for such items as travel, legal fees, rental of vehicles and any other administrative expenses. Include
the amount of interest expense when authorized by program legislation.
Enter the amounts pertaining to the work of locating and designing, making surveys and maps, sinking test holes, and all other
work required prior to actual construction.
Enter all amounts directly associated with the acquisition of land, existing structures, and related right-of-way (this includes
purchase, lease, and/or easements).
Enter basic fees for services of architectural engineers relating to construction (this includes start-up services and preparation
of project performance work plan).
Enter amounts for other architectural engineering services, such as surveys, tests, soil borings, etc. Do not include any amounts
shown on line 11d.
Enter construction monitoring, engineering inspection, and audit fees of construction and related programs.11g. Enter all
amounts associated with the development of land where the primary purpose of the grant is land improvement.
Enter the dollar amounts used to provide relocation advisory assistance and net costs of replacement housing.
Enter the amount of relocation payments made by the recipient to displaced persons, farms, business concerns, and nonprofit
organizations
Enter gross salaries and wages of employees of the recipient and payments to third party contractors directly engaged in
performing demolition or removal of structures from developed land.
Enter those amounts associated with the actual construction of, addition to, or restoration of a facility. Also, include the amounts
for project improvements such as sewers, streets, landscaping and lighting.
Enter amounts for all equipment, both fixed and movable, exclusive of equipment used for construction.
Enter the amounts for all items not specifically mentioned above.
Enter the total cumulative amount to date which should be the sum of lines 11a through 11m.
Enter the total amount of program income applied to the grant or contract agreement except income on line j. Identify on a
separate sheet of paper the sources and types of the income.
Enter the net cumulative amount to date which should be the amount shown on line 11n minus the amount on line11o.
Enter the Federal share of the amount shown on line 11p.
Enter the amount of rehabilitation grant payments made to individuals when program legislation provides 100 percent payment
by the Federal agency. 11s. Enter the total amount of Federal share.
Enter the total amount of Federal payments previously requested, if this form is used for requesting reimbursement.
Enter the total amount being requested for reimbursement. This amount should be the difference between the amounts shown
on lines 11q and 11t. If different, explain on a separate sheet.
Enter the actual percentage of project already constructed. 12. The purpose of this item is to verify that the costs or
disbursements are in accordance with the terms of the project. 12a. To be completed by the recipient official who is
responsible for preparation and submission of the outlay report. 12b. To be completed by the official representative who is
certifying to the percent of project completion as provided for in the terms of the grant or cooperative agreement. Refer to
Outlays Module, Part III, for detailed instructions.