83c

PAPERWORK REDUCTION ACT

CHANGE WORKSHEET

Agency/subagency

OMB Control Number

DHS-USCIS

0040
1615
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Enter only items that change
Current record

New record

Agency form number (s)

I-765; I-765WS

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**

USCIS is adding Temporary Protected Status categories to online filing of Form I-765, Application for Employment
Authorization.
Signature of Senior Official or designee:

JERRY L RIGDON

Digitally signed by JERRY L
RIGDON
Date: 2021.06.22 12:02:17 -04'00'

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

OMB 83-C

Date:

For OIRA Use
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10/95