Form FEMA Form 009-0-13 FEMA Form 009-0-13 Unit Installation Work Order

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
MANUFACTURED HOUSING UNIT (MHU) INSTALLATION WORK ORDER

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

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 form to the above
address.

DRAFT
NOT
APPROVED
FOR
USE
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.
1. SITE CONTROL #:

2. WORK ORDER #:

3. APPLICATION/SITE INFORMATION
REGISTRATION ID:

NAME (Last, First, Middle Initial):

DATE ISSUED:

SITE ADDRESS (House # and Street Name or Pad #, City, State, County):

4. CONTRACT WORK ORDER INFORMATION
CONTRACTOR:

INSPECTOR:

5. SITE TYPE

Commercial

ISSUED BY:

6. UNIT TYPE

Group

DATE SCH. COMPLETION:

7. UNIT #

MHU

OTHER

Private

9. PAD LOT INFORMATION

8. UNIT INFORMATION
UNIT TYPE

STANDARD

Barcode

Pad Lot #

Pad Lot Type

Rent Amt.

Make

VIN

Pad Lot Size

Split Lot?

Model

Furnished?

Year

# Bedrooms

FEMA FORM 009-0-136 (05/14)

OUFAS

Yes

No

Yes

No

Amps

Utilities

REPLACES FEMA Form 90-26

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MANUFACTURED HOUSING UNIT (MHU) INSTALLATION WORK ORDER
10. INSTALLATION
ITEM # (Check if
ITEMS TO FURNISH AND INSTALL
applicable)

UNIT

QUANTITY

UNIT $

TOTAL $

Basic Setup

DRAFT
NOT
APPROVED
FOR
USE
4" Sewer Line, Buried
6" Sewer Line, Buried
8" Sewer Line, Buried
Municipal Sewer

3/4" Water Line Extension, Buried
2" Water Line Extension, Buried
Municipal Water

Power Pole and Meter Loop - AMP

Additional Towing Outside - Mile Radius
Heavy Equipment to Spot

Winterize Water Line Installation
Direct Wiring of

AMP Service, Over 50'

Direct Wiring of Well Pump
30 AMP Well Pump Switch

LP Gas System and 100 Gallon LP
Natural Gas Hookup

Gas Line Extension, Underground
Skirting

Permits

Steps (Per Entrance)

Visual/Vibration/Enhanced volume Alarm
Accessible Ramp
Roll in Shower

Accessible Platform Steps
Grab bars/Bathroom
Visual Alarms

Roll in Shower

Accessible Unit

WORK ORDER TOTAL

FEMA FORM 009-0-136 (05/14)

REPLACES FEMA Form 90-26

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