83c

PAPERWORK REDUCTION ACT

CHANGE WORKSHEET

Agency/subagency

OMB Control Number

DHS/USCIS

0096
1615
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Enter only items that change
Current record

New record

Agency form number (s)

G-1041; G-1041A

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-1041 and G-1041A increase as a result of the final rule titled U.S. Citizenship and Immigration
Services Fee Schedule and Changes to Certain Other Immigration Benefits Requests, 1615-AC18. Other 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:

7/20/2020
** This form cannot be used to extend an expiration date.

OMB 83-C

For OIRA Use
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10/95