FEMA Form 009-0-12 Applicant's Benefits Calculation Worksheet

DEPARTMENT OF HOMELAND SECURITY

O.M.B. Control Number: 1660-0017

Federal Emergency Management Agency
APPLICANT'S BENEFITS CALCULATION WORKSHEET

Expires: December 31, 2019

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average .5 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 this form. This collection of information is not
required to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper
right corner of 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, Paperwork Reduction
Project (1660-0017) NOTE: Do not send your completed form to this address.
APPLICANT

PA ID #

DISASTER

PROJECT #
FRINGE BENEFITS (by %)

REGULAR TIME

OVERTIME

HOLIDAYS
VACATION LEAVE
SICK LEAVE
SOCIAL SECURITY
MEDICARE
UNEMPLOYMENT
WORKER'S COMP.
RETIREMENT
HEALTH BENEFITS
LIFE INS. BENEFITS
OTHER
TOTAL IN % ANNUAL SALARY
COMMENTS

I CERTIFY THAT THE INFORMATION ABOVE WAS TRANSCRIBED FROM PAYROLL RECORDS OR OTHER DOCUMENTS WHICH ARE AVAILABLE
NAME

FEMA FORM 009-0-128

TITLE

PREVIOUS EDITION OBSOLETE

DATE