Change Request Form

PAPERWORK REDUCTION ACT

CHANGE WORKSHEET

Agency/subagency

OMB Control Number

Corporation for National and Community Service

0174
3045
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Enter only items that change
Current record

New record

Agency form number (s)

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**

We would like to remove three survey questions and slightly modify three additional survey questions. There will be a
negligible reduction in burden to respondents, therefore we anticipate that the total annual hours will remain at the approved
level of 1266 hours.
Signature of Senior Official or designee:

** This form cannot be used to extend an expiration date.

OMB 83-C

Date:

For OIRA Use
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10/95