2011 Burden

Burden Computation - Business Forms
Page 1 of 1

March 30, 2011

Product:
Description:
Variables
Responses.......
Line Items......
Attachments.....
Forms Prepared..
Code References.

2678/
Employer/Payer Appointment Agent
2011

Changes (+ -)

2011

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

+6,034,800
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________

6,130,000
______________
6
______________
0.00
______________
0.00
______________
0
______________

Computation of Changes
6,130,000 x _____________
0.88
Old Computation (Prog. Change) ______________
6,130,000
0.88
New Computation.............. ______________ x _____________
Balance...

=
=

5,394,400
_______________
5,394,400
_______________
_______________
0

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

95,200 x _____________
0.88
______________
______________
6,130,000 x _____________
0.88

=
=

83,776
_______________
_______________
5,394,400
_______________
+5,310,624

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

______________ x _____________
______________ x _____________

=
=

_______________
_______________
_______________

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

83,776
_______________
0
_______________
+5,310,624
_______________
5,394,400
_______________

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.
___________________