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pdfDEPARTMENT OF HOMELAND SECURITY
OMB Control Number: 1660-0017
Expires: November 30, 2025
Federal Emergency Management Agency
MATERIALS SUMMARY RECORD
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
VENDOR
DESCRIPTION
QUAN.
UNIT
PRICE
TOTAL
PRICE
DATE
PURCHASED
DATE
USED
INFO FROM (CHECK ONE)
STOCK
INVOICE
GRAND TOTAL
CERTIFIED
FEMA Form FF-104-FY-21-138 (formerly 009-0-124)
(3/22)
TITLE
DATE
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| File Type | application/pdf |
| File Title | FEMA Form FF-104-FY-21-138 |
| Subject | MATERIALS SUMMARY RECORD |
| Author | FEMA |
| File Modified | 2022-12-01 |
| File Created | 2022-03-14 |