Signed OMB 83-C

PAPERWORK REDUCTION ACT
CHANGE WORKSHEET
OMB Control Number

Agency/subagency
Department of Homeland Security/FEMA

• 0061
1660
-------Enter only items that change
Current record

Agency form number (s)

New record
FEMA Form 010-0-12S (Spanish)
(New Form)

FEMA Form 010-0-12 (English)

FEMA Form:
FEMA Form 010-0-12S
Annual reporting and recordkeeping hour
burden
Number of respondents
Total annual responses
Percent of these responses
collected electronically

%

%

Total annual hours
~

Difference
Explanation of difference
Program change
Adjustment
Annual reporting and recordkeeping cost
burden (in thousands of dollars)

..
.!

Total annualized Capital/Startup costs
Total annual costs (O&M)
Total annualized cost requested
Difference
Explanation of difference
Program change
Adjustment
Other changes**
FEMA has added a Spanish version to FEMA Form 010-0-12. There is no burden change or change to the scope of the
collection since the last approvaL The new form number is FEMA Form 010-0-12S. Some of the burden from the English
has been transferred to the Spanish form - 13, 440 hours.

Sj!ln~uro

of Sen" rOIIicial orl~i

~~rthil, Dire~Tor.~ecor

nage

, Division

..........,
** Th1s form cannot be used to extend an exp1rat1on date.
OMB 83-C

Date:

for~

ForOIRA Use

7/2/12

10/95