2012 Burden

Burden Computation - Special Business Forms
Page 1 of 1

November 14, 2012

Product:
Description:
Variables
Responses.......
Line Items......
Forms Prepared..

5754/
Statement by Person(s) Receiving Gambling Winnings
2009

Changes (+ -)

2012

204,000
______________
13
______________
0.85
______________

_____________________________
_____________________________
_____________________________

204,000
______________
13
______________
0.85
______________

Computation of Changes
204,000 x _____________
0.20
Old Computation (Prog. Change) ______________
204,000 x _____________
0.20
New Computation.............. ______________
Balance...

=
=

40,800
_______________
40,800
_______________
0
_______________

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

______________ x _____________
______________ x _____________

=
=

_______________
_______________
_______________

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

______________ x _____________
______________ x _____________

=
=

_______________
_______________
_______________

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

40,800
_______________
0
_______________
_______________
40,800
_______________

Paperwork Reduction Act Notice
Time Per Response
0.20
Record Keeping............
Learning..................
Preparing.................
Sending...................

Notes:

Average Hours
Per Response
______________
______________
______________
0.20
______________

Average Time
Per Response
___________________
___________________
___________________
0 hrs. , 12 min.
___________________