Signed Change Request Form

PAPERWORK REDUCTION ACT

CHANGE WORKSHEET

Agency/subagency

OMB Control Number

Department of Homeland Security/FEMA

0017
1660
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___ ___ - ___
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Enter only items that change
Current record

Agency form number (s)

New record

FEMA Template 104-FY-21-100
Equitable COVID-19 Response and
Recovery

--

FEMA Template 104-FY-21-100
Equitable COVID-19 Response and
Recovery
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 form was discussed in the documentation of the recent emergency request approved by OMB on April 29, 2021, but was
inadvertently not included in ROCIS.
Signature of Senior Official or designee:

SAMUEL C RONVEAUX

Date:
Digitally signed by SAMUEL C
RONVEAUX
Date: 2021.05.17 07:02:21 -05'00'

** This form cannot be used to extend an expiration date.

OMB 83-C

5/17/21

For OIRA Use
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10/95