OMB 83c

PAPERWORK REDUCTION ACT

CHANGE WORKSHEET

Agency/subagency

OMB Control Number

Department of Homeland Security/U.S. Citizenship and Naturalization Services
Enter only items that change
Current record
Agency form number (s)

The current form is offered in paper for
delivery to the agency via physical mail.

N-565

0091
1615
___ ___
___ ___ - ___
___ ___ ___

New record

The new form is presented in electronic
format for electronic submission
through an on-line USCIS account.

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**

Signature of Senior Official or designee:

MEEKA S SMITH

Digitally signed by MEEKA S SMITH
DN: c=US, o=U.S. Government, ou=Department of Homeland Security,
ou=USCIS, ou=People, cn=MEEKA S SMITH,
0.9.2342.19200300.100.1.1=0514459744.USCIS.1
Date: 2018.05.02 12:13:11 -04'00'

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

OMB 83-C

Date:

5/2/2018

For OIRA Use
___________________________________
___________________________________

10/95