83c

PAPERWORK REDUCTION ACT

CHANGE WORKSHEET

Agency/subagency

OMB Control Number

DHS/USCIS

0030
1615
___ ___
___ ___ - ___
___ ___ ___
Enter only items that change
Current record

New record

Agency form number (s)

I-612

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**

The fee for Form I-612 is increasing as a result of the final rule titled U.S. Citizenship and Immigration Services Fee Schedule
(published as a Notice of Proposed Rulemaking on May 4 2016 at 81 FR 26094-40). For Form I-612, the fee is increasing
from $585 to $930
Signature of Senior Official or designee:

Date:

Digitally signed by [email protected]

[email protected] DN: [email protected]
Date: 2016.10.24 17:53:40 -04'00'

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

OMB 83-C

9/12/2016

For OIRA Use
___________________________________
___________________________________

10/95