83-c

PAPERWORK REDUCTION ACT
CHANGE WORKSHEET
IMB ControlNumber

Agencylsubagency

1615

DHSruSCE
Enter only items thatchange
Cunent record

.0040

Nerv record

Agency form number (s)

t-765

l

Annual reporting and recordkeeping hour
burden
Number of respondents

Total annual responses
Percent of these response

8,159,070

Tota! annual hours

o/o

o/o

collected elec{ronically

8,159,429

3s9

Difference
Explanation of diffErence
Program change
Adius{ment
Annual reporting and recordkeeping cost
burden (in thousands of dollars)
Total annualized CapitaUStartup costs
Total annual costs (O&M)
Total annualized cost rquested
ii

Difference
Explanation of difference
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Program change

Adiustment

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Jther changes*

The curreht hour inventory approved for this form is 8,159,070 hours, and the requested new total hour burden is 8,159,429,
which is an increase of 359 annual burden hours, due to an updated estimate of the relative number of paper filers vs
electronic filers.
Signature of Senior

fficial

or designee:

ilr\

{ At!
'J\
*

Date:

For OIRA Use

jircl1 tb

This lorm cannot be used to ertend an expiration dafe-

oMB 83.C

10195