83c

PAPERWORK REDUCTION ACT

CHANGE WORKSHEET

Agency/subagency

OMB Control Number

DHS/USCIS

0136
1615
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Enter only items that change
Current record

New record

Agency form number (s)

I-941

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**

USCIS requests a modification to the Terms of Clearance in the July 7, 2017 Notice of action. USCIS requests that the
effective date of the form be changed to December 1, 2017.
Signature of Senior Official or designee:

john.r.ramsay@us
cis.dhs.gov

Digitally signed by
[email protected]
DN: [email protected]
Date: 2017.12.08 14:23:31 -05'00'

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

OMB 83-C

Date:

12/7/2017

For OIRA Use
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10/95