83c

PAPERWORK REDUCTION ACT

CHANGE WORKSHEET

Agency/subagency

OMB Control Number

DHS/USCIS

0105
1615
___ ___
___ ___ - ___
___ ___ ___
Enter only items that change
Current record

New record

Agency form number (s)

G-28
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 USCIS Form G-28 would remain unchanged at $0 as a result of the proposed rule titled U.S. Citizenship and
Immigration Services Fee Schedule and Changes to Certain Other Immigration Benefits Requests, 1615-AC18. Other
proposed changes to this information collection are listed in the Table of Changes submitted to OIRA as part of the rule
package.
Signature of Senior Official or designee:
Date:
For OIRA Use
___________________________________
___________________________________
11/4/2019
** This form cannot be used to extend an expiration date.

OMB 83-C

10/95