Signed OMB 83-C for HUD-90021-ORCF

Paperwork Reduction Act
Change Worksheet
Agency/Sub agency:

OMB Control Number:

U.S. Department of Housing and Urban Development

2502-0605

Enter only items that change
Agency form number(s):

Current Record

N/A

HUD-90021-ORCF

New Record**

N/A

Annual reporting and keeping hour burden
Number of respondents
Total annual responses
Percent of these responses collected electronically

%

%

Total annual hours
Difference

0

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

0

Explanation of difference
Program change
Adjustment
Other change: **

Here explain/describe the changes to HUD-90021-ORCF form to OMB:
Revise language in HUD-90021-ORCF, Part II. Previous Participation Certification section due to Scrivener
error. This same standard language is included and approved in the following OMB-approved documents in this
collection: 90012, 90013, 90014, 90015, 90016, 90017, 90018. No additional burden hours are required.

Signature of Senior Official or Designee:

Date:

For OIRA Use

8/6/20

John Hartung, Director, Policy, Risk Analysis and Lender Relations
Division, Office of Residential Care Facilities , HP

** This form cannot be used to extend an expiration date.
OMB 83-C

10/95