2011 Burden

Burden Computation - Business Forms
Page 1 of 1

March 30, 2011

Product:
Description:

2678/
Employer/Payer Appointment Agent

Variables
Responses.......
Line Items......
Attachments.....
Forms Prepared..
Code References.

______________
______________
______________
______________
______________

Changes (+ -)

2011

+95,200
_____________________________
+6
_____________________________
_____________________________
_____________________________
_____________________________

95,200
______________
6
______________
0.00
______________
0.00
______________
0
______________

Computation of Changes
95,200 x _____________
Old Computation (Prog. Change) ______________
95,200 x _____________
0.88
New Computation.............. ______________
Balance...

=
=

_______________
83,776
_______________
_______________
+83,776

Old Computation (Adjustment).
New Computation..............
Balance...

______________ x _____________
______________
95,200 x _____________

=
=

_______________
_______________
_______________

Old Computation..............
New Computation..............
Balance...

______________ x _____________
______________ x _____________

=
=

_______________
_______________
_______________

Summary
Old Burden...................................................
Program Change...............................................
Adjustment...................................................
New Burden...................................................

_______________
+83,776
_______________
_______________
83,776
_______________

Paperwork Reduction Act Notice
Time Per Response
0.88
Recordkeeping.............
Learning..................
Preparing.................
Sending...................

Notes:

Average Hours
Per Response
0.73
______________
0.00
______________
0.16
______________
0.00
______________

Average Time
Per Response
0 hrs. , 43 min.
___________________
0 hrs. , 00 min.
___________________
0 hrs. , 09 min.
___________________
0 hrs. , 00 min.
___________________