Form FEMA Form FF-104-F FEMA Form FF-104-F Materials Summary Record

DEPARTMENT 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

Page 1 of 1