Justification for Change
OMB #1510-0077
Request for Payment of Federal Benefit by Check, EFT Waiver Form
FMS 1201W
A Spanish version of the waiver form has been created to provide a user-friendly format for ease of use by Spanish-speaking recipients; therefore less burdensome on those recipients.
We estimate that the total number of Spanish-speaking respondents is estimated at 210 or 7% of the total number of forms received. There is no change to the total number of response or burden hours currently approved.
FMS 1201-W |
#Respondents |
#Responses Per Respondent |
Total Annual Responses |
Hours Per Response |
Total Annual Burden |
English |
2790 |
1 |
2790 |
0.33 |
930 |
Spanish |
210 |
1 |
210 |
0.33 |
70 |
Totals |
3000 |
1 |
3000 |
0.33 |
1000 |
January 2014
| File Type | application/msword |
| Author | Wolfgang, Dawn |
| Last Modified By | Wolfgang, Dawn |
| File Modified | 2014-01-23 |
| File Created | 2014-01-23 |