Form FEMA Form 009-0-13 FEMA Form 009-0-13 Maintenance Work Order

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB Control Number.: 1660-0030
Expiration Date: MM/DD/YYYY

MANUFACTURED HOUSING UNIT MAINTENANCE WORK ORDER
PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this form is estimated to average 10 minutes per response. The burden estimate includes the time for reviewing
instructions, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form.
This collection of information is mandatory. You are not required to respond to this collection of information unless a valid OMB control number
appears in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing
this burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C
Street, SW, Washington, DC, 20472, Paperwork Reduction Project (1660-0030). Please do not send your completed survey to the above
address.
PRIVACY ACT STATEMENT
AUTHORITY: The Robert T. Stafford Disaster Relief and Emergency Assistance Act as amended, 42 U.S.C. § 5174 and Title 44 C.F.R. Part
206.117.
PRINCIPAL PURPOSE(S): This information is being collected for the primary purpose of obtaining necessary landowner consent to inspect
site, place maintain, deactivate and/or remove temporary housing units provided by FEMA to eligible registered disaster survivors as part of its
direct housing program under a Presidentially-declared disaster.
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974,
as amended. This includes using this information as necessary and authorized by the routine uses published in DHS/FEMA - 008 Disaster
Recovery Assistance Files System of Records, 78 Fed. Reg. 25282 (Apr. 30, 2013), and upon written request, by agreement, or as required by
law.
DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay or
prevent the individual from receiving disaster-related temporary housing assistance.
WO Type:

Contractor:

Work Order #:

WORK ORDER STATUS:

AS OF:
Occupant Information

Name:

Phone #:

Address:

Lot #:

Site:

State:

City:

Maintenance Request Information
Unit #:

Received:

Unit Type:
Date

County:

Received by:

Time
Yes

Permission to Enter?
Occupant Available:

Date:

Problem Previously Reported?

Yes

No

Time:
No

If Yes, Please Explain:

Deactivation Return Information
Site:

City:

State:

County:

Zip:

Address:
Work Order Issue Information
Issued to:

Issued Date:

Issue Time:

Issued by:

Date Completed:

Description of Work Completed:

FEMA FORM 009-0-130 (04/15)

REPLACES FEMA Form 90-38

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Work Order Notes:

Signatures: (Certification that the above described work has been completed) Notes: provide copy to occupants
Contractor

Date

Contractor Project Officer

Date

Occupant

Date
Work Order Specifications
UOM

Description

Quantity

Cost Per UOM

Total

Labor
Work Began

Work Completed
Time

Date

AM

Time

Date
PM

AM

PM

Total hours worked (24 hour increments)
Verification and Signatures: The above described work has been verified by:
Phone

Inspection and complies with

Maintenance Coordinator

Date

Project Officer

Date

Charge Work Order to:

Manufacturer

FEMA FORM 009-0-130 (04/15)

Setup Contractor

Maintenance Contractor

REPLACES FEMA Form 90-38

Occupant

Other

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