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pdfDEPARTMENT 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)
Page 1 of 2
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
Page 2 of 2
File Type | application/pdf |
File Title | FEMA Form FF-104-FY-21-113 |
Subject | MANUFACTURED HOUSING UNIT MAINTENANCE WORK ORDER |
File Modified | 2021-12-22 |
File Created | 2021-03-11 |