OMB 83 C Change Worksheet

PAPERWORK REDUCTION ACT

CHANGE WORKSHEET

Agency/Subagency U.S. Department of Housing and Urban Development Office of Housing, Office of Single Family Program Development							OMB Control Number 2502-0542
Enter only items that change Current record New record
Agency form number(s) HUD-96011 HUD-2994-A
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** The Assisted Living Conversion Program has always included these two forms however they were not listed in the ICR. They are standard grant forms included in HUD’s SuperNOFAs. Both forms are approved under other control numbers and do not add to the burden of 2502-0542. Forms are: HUD-2994-A, You Are Our Client! Survey, approved under 2535-0116 HUD-96011, Third Party Documentation, Facsimile Transmittal, approved under 2535-0118.
Signature of Senior Official or designee:						Date:	For OIRA Use _______________ ______________

**This form cannot be used to extend an expiration date.

OMB FORM 83-C 10/95