I-912 83c

PAPERWORK REDUCTION ACT

CHANGE WORKSHEET

Agency/subagency

OMB Control Number

DHS/ USCIS

0116
1615
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Enter only items that change
Current record

New record

Agency form number (s)

I-912

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**

With the promulgation of the Inadmissibility on the Grounds of Public Charge Final Rulemaking, a request for a Fee Waiver
would become a factor in the determination of Public Charge. Currently, there is no determination grounds. With this update,
the I-912 would provide warning that a request for a fee waiver may be a factor in the public charge determination.
Signature of Senior Official or designee:

Date:

8/14/2019
** This form cannot be used to extend an expiration date.

OMB 83-C

For OIRA Use
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10/95