OMB-83c

PAPERWORK REDUCTION ACT
CHANGE WORKSHEET
Agency/Subagency

OMB control number

DHS/TSA

1

6

5

2

0

0

5

6

Enter only items that change
Current record
New record
Agency form number(s)

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

%

%

Total annual hours

0

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)

0.00

Total annualized cost requested

0.00
0.00

Difference
Explanation of difference
Program change
Adjustment
Other changes**

Certification of Completion: For convenience, TSA will provide an optional form (TSA Security Directive Pipeline 2021-02 Statement of
Completion) for each submission deadline that Owner/Operators can complete and submit via email. This form is SSI/need to know only
Signature of Senior Official or designee:

Christina A. Walsh
**This form cannot be used to extend an expiration date.
OMB FORM 83-C, 10/95

Date:

For OIRA Use

8/18/2021

Reset

Adobe Professional 7.0