FEMA FORM 009-0-120
PREVIOUS EDITION OBSOLETE
FEMA Form 009-0-126 PREVIOUS EDITION OBSOLETE
DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
O.M.B. Control Number: 1660-0017
Expires: June 30, 2020
CONTRACT WORK 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.
PAGE OF
DATE PA ID # PROJECT # DISASTER
LOCATION/SITE CATEGORY PERIOD COVERING
DESCRIPTION OF WORK PERFORMED
DATES WORKED CONTRACTOR
BILLING/INVOICE
NUMBER
AMOUNT COMMENTS- SCOPE
GRAND TOTAL
I CERTIFY THAT THE INFORMATION WAS OBTAINED FROM PAYROLL, INVOICES, OR OTHER DOCUMENT THAT ARE AVAILABLE FOR AUDIT.
CERTIFIED TITLE DATE
