Reporting and Recordkeeping Requirements

INSTRUCTIONS: Use this form when a single information collection document involves multiple reporting and recordkeeping requirements. The totals of the figures in cols. should be entered in item 13 of OMB-83-I: cols. (D) &/or (I) = 13a (respondent is only counted once); cols. F & I = 13b; cols. H & K = 13c. (F)Total/(D)Total = (E)Average (H)Total/(F)Total = (G)Average (K)Total/(I)Total = (J)Average NOTE: The columns will calculate automatically. If Col. E's response is something other than annually, i.e., 1/6 years, list as "1/6" & decimal will display.								TITLE OF INFORMATION COLLECTION DOCUMENT						OMB NO.	0560-0190
								Power of Attorney
														DATE PREPARED
														January 22, 2020
														IDENTIFICATION OF REPORTING OR RECORDKEEPING REQUIREMENT							ANNUAL BURDEN
							REPORTS						RECORDS			RESPONDENT COST
											TOTAL BURDEN HOURS				TOTAL
						FORMS NO (S)	NO. OF	NO OF	TOTAL ANNUAL	HOURS	(Col. F x G)		NO. OF	ANNUAL	RECORD-	COST	TOTAL
SECTION OF	DESCRIPTION					(If "none"	RESPONDENTS	RESPONSES	RESPONSES	PER	(H)		RECORD-	HOURS PER	KEEPING HOURS	PER	COST
REGS.						so state)		PER	(Col. D x E)	RESPONSE			KEEPERS	RECORD-	(Col. I x J)	HOUR	(Col. H x L)
								RESPONDENT			EXEMPT	NON-EXEMPT		KEEPER
(A)	(B)					(C)	(D)	(E)	(F)	(G)			(I)	(J)	(K)	(L)	(M)
	Power of Attorney					FSA-211	12,000	1	12,000	0.50		6,000				$53.71	322,260
	Power of Attorney -Continuation					FSA-211A	896	1	896	0.25		224				$53.71	12,031
								1	0			0					0
								1	0			0					0
								1	0			0					0
								1	0			0					0
								1	0			0					0
								1	0		0
								1	0		0
	SUBTOTAL								12,000		0	6,224			0.00		334,291
	TOTAL OF ALL PAGES								12,000		0	6,224			0.00		334,291
TOTAL - COLUMNS "F" AND "I" = OMB 83-I, 13b; COLUMNS "H" AND "K" = OMB 83-I, 13c									12,000			6,224