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**

On July 29, 2020, DHS was enjoined by the U.S. District Court for the Southern District of New York from enforcing, applying,
implementing, or treating as effective the Public Charge Final Rule. The injunction covers the use of the information collection
instruments approved with the Rule requiring the changes made related to rule to be removed. Changes are available in the
Table of Changes.
Signature of Senior Official or designee:
Date:
For OIRA Use
___________________________________
___________________________________
8/5/2020
** This form cannot be used to extend an expiration date.

OMB 83-C

10/95