Reporting and Recordkeeping Requirement

INSTRUCTIONS: Use this form when a single information collection document involves multiple reporting and recordkeeping requirements. The totals of the figures in cols. should be entered in item 13 of OMB-83-I: cols. (D) &/or (I) = 13a (respondent is only counted once); cols. F & I = 13b; cols. H & K = 13c. (F)Total/(D)Total = (E)Average (H)Total/(F)Total = (G)Average (K)Total/(I)Total = (J)Average NOTE: The columns will calculate automatically. If Col. E's response is something other than annually, i.e., 1/6 years, list as "1/6" & decimal will display.

TITLE OF INFORMATION COLLECTION DOCUMENT

OMB NO.

0560-0190

Power of Attorney

DATE PREPARED

July 31, 2023

IDENTIFICATION OF REPORTING OR RECORDKEEPING REQUIREMENT

ANNUAL BURDEN

REPORTS

RECORDS

RESPONDENT COST

TOTAL BURDEN HOURS

TOTAL

FORMS NO (S)

NO. OF

NO OF

TOTAL ANNUAL

HOURS

(Col. F x G)

NO. OF

ANNUAL

RECORD-

COST

TOTAL

SECTION OF

DESCRIPTION

(If "none"

RESPONDENTS

RESPONSES

RESPONSES

PER

(H)

RECORD-

HOURS PER

KEEPING HOURS

PER

COST

REGS.

so state)

PER

(Col. D x E)

RESPONSE

KEEPERS

RECORD-

(Col. I x J)

HOUR

(Col. H x L)

RESPONDENT

EXEMPT

NON-EXEMPT

KEEPER

(A)

(B)

(C)

(D)

(E)

(F)

(G)

(I)

(J)

(K)

(L)

(M)

Power of Attorney

FSA-211

15,000

1

15,000

0.50

7,500

$62.55

469,125

Power of Attorney -Continuation

FSA-211A

1,000

1

1,000

0.25

250

$62.55

15,638

SUBTOTAL

16,000

0

7,750

0.00

484,763

TOTAL OF ALL PAGES

16,000

0

7,750

0.00

484,763

TOTAL - COLUMNS "F" AND "I" = OMB 83-I, 13b; COLUMNS "H" AND "K" = OMB 83-I, 13c

16,000

7,750