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FEDERAL EMERGENCY MANAGEMENT AGENCY

CONTRACT WORK SUMMARY RECORD

Page                     of

1. APPLICANT

2. PA ID

3. PW #

4. DISASTER NUMBER

5. LOCATION/SITE

6. CATEGORY

7. PERIOD COVERING

to

8. DESCRIPTION OF WORK PERFORMED

DATES WORKED

CONTRACTOR

BILLING/INVOICE NUMBER

AMOUNT

COMMENTS–SCOPE

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$

 

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$

 

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$

 

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$

 

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$

 

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GRAND TOTAL

$

 

I CERTIFY THAT THE ABOVE INFORMATION WAS OBTAINED FROM PAYROLL RECORDS, INVOICES, OR OTHER DOCUMENTS THAT ARE AVAILABLE FOR AUDIT.

CERTIFIED

TITLE

DATE

FEMA Form 90-126, NOV 98