OMB Form 83-C

PAPERWORK REDUCTION ACT

CHANGE WORKSHEET

Agency/subagency

OMB Control Number

DHS/ICE

0048
1653
___ ___
___ ___ - ___
___ ___ ___
Enter only items that change
Current record

New record

Agency form number (s)

73-028

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**

Change to form name only. Currently listed as "ICE Mutual Agreement Between Government and Employers (IMAGE)
Membership Application". New name will be "ICE Mutual Agreement Between Government and Employers (IMAGE) Self
Assessment Questionnaire".
Signature of Senior Official or designee:

John Ramsay, Program (Forms) Manager
** This form cannot be used to extend an expiration date.

OMB 83-C

Date:

11/1/2011

For OIRA Use
___________________________________
___________________________________

10/95