Form FF-104-FY-21-113 ( FF-104-FY-21-113 ( Transportable Temporary Housing Unit Maintenance Work Or

DEPARTMENT OF HOMELAND SECURITY

OMB Control Number: 1660-0030
Expiration Date: 01/31/2024

Federal Emergency Management Agency

TRANSPORTABLE TEMPORARY 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 0MB 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 his 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 information specific to a FEMA provided
transportable temporary housing unit (TTHU) in order to assess and perform maintenance as part of direct housing assistance under a Presidentiallydeclared 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 197 4, 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 applicant from receiving disaster-related temporary housing assistance.

Work Order Type:

Contractor:

DRAFT

WORK ORDER STATUS:

AS OF:

OCCUPANT INFORMATION
Phone #:
Lot #:

Name:
Address:

Date

Work Order #:

City:

Issued:

Time

Permission to Enter?
Yes
No

State:

MAINTENANCE REQUEST INFORMATION
TTHU Type:
TTHU #:

Occupant Available:
Date:

Problem Previously Reported?

Zip Code:

Yes

Site:
County/Parish:

Received by:

Time:
No

If Yes, Please Explain:

Site:

DEACTIVATION RETURN INFORMATION
Address:

City:

Issued to:

State:

County/Parish:

WORK ORDER ISSUE INFORMATION

Issued by:

Issued Date:

Zip:

Issue Time:

Date Completed:

Description of Work Completed:

FEMA Form FF-104-FY-21-113 (formerly 009-0-130)
(12/21)

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Work Order Notes:

Contractor

SIGNATURES
(Certification that the above described work has been completed) Notes: Provide copy to occupants
Date

Contractor Project Officer

Date

Occupant

Date

WORK ORDER SPECIFICATIONS
Unit Of Measure
Quantity
(UOM)

Description

Date

Work Began
Time

Cost Per UOM

DRAFT
AM

Phone

Date

LABOR
Work Completed
Time

PM
AM
VERIFICATION AND SIGNATURES:
The above described work has been verified by:

Total hours worked (24-hour
increments)

PM

Inspection and complies with

Maintenance Coordinator

Date

Project Officer

Date

Charge Work Order to:

Total

Manufacturer

Setup Contractor

FEMA Form FF-104-FY-21-113 (formerly 009-0-130)
(12/21)

Maintenance Contractor

Occupant

Other T

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