Form FF-104-FY-21-112 ( FF-104-FY-21-112 ( Transportable Temporary Housing Unit Installation Work O

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
TRANSPORTABLE TEMPORARY HOUSING UNIT
INSTALLATION WORK ORDER

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

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 OMB 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
this 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 form 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 documenting the process and current status of
installing transportable temporary housing units (TTHUs) provided by FEMA to eligible applicants as part of direct housing assistance under a
Presidentially-declared 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 1974,
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.

DRAFT

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.
1. SITE CONTROL #:

2. WORK ORDER #:

3. APPLICATION/SITE INFORMATION

REGISTRATION ID:

NAME (Last, First, Middle Initial):

DATE ISSUED:

SITE ADDRESS (House # and Street Name or Pad #, City, State, County/Parish):

4. CONTRACT WORK ORDER INFORMATION
CONTRACTOR:

INSPECTOR:

5. SITE TYPE

ISSUED BY:

6. TTHU TYPE

DATE SCH. COMPLETION:

7. ELEVATION REQUIRED?

Commercial Park

Group Site

MHU

YES, to

Private Site

Other

OTHER

NO
9. TTHU INFORMATION

8. UNIT INFORMATION
UNIT TYPE

VIN #

Barcode

Pad Lot #

Make

Tank and Pump System Barcode

Model

Furnished?

Year

# Bedrooms

FEMA Form FF-104-FY-21-112 (formerly 009-0-136)
(12/21)

OUFAS
Pad Lot Type

Yes

No

Pad Lot Size
Split Lot?

Yes

No

Amps
Utilities

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TRANSPORTABLE TEMPORARY HOUSING UNIT INSTALLATION WORK ORDER
10. INSTALLATION
ITEM # (Check if
applicable)

ITEMS TO FURNISH AND INSTALL

UNIT

QUANTITY

UNIT $

TOTAL $

Basic Setup
4" Sewer Line, Buried
6" Sewer Line, Buried
8" Sewer Line, Buried
Municipal Sewer
3/4" Water Line Extension, Buried
2" Water Line Extension, Buried
Municipal Water
Power Pole and Meter Loop - AMP
Additional Towing Outside - Mile Radius

DRAFT

Heavy Equipment to Spot

Winterize Water Line Installation
Direct Wiring of

AMP Service, Over 50'

Direct Wiring of Well Pump
30 AMP Well Pump Switch

LP Gas System and 100 Gallon LP
Natural Gas Hookup
Gas Line Extension, Underground
Skirting
Permits
Steps (Per Entrance)

Visual/Vibration/Enhanced volume Alarm
Accessible Ramp
Accessible Unit
Accessible Platform Steps
Grab bars/Bathroom
Visual Alarms
Roll in Shower
WORK ORDER TOTAL
Comments:

FEMA Form FF-104-FY-21-112 (formerly 009-0-136)
(12/21)

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