Burden Computation

Burden Computation - Special Business Forms
Page 1 of 1

June 4, 2008

Product:
Description:
Variables
Responses.......
Line Items......
Forms Prepared..

5498SA/
HSA, Archer MSA, or Medicare Advantage MSA Information
2005

Changes (+ -)

2008

41,105
______________
11
______________
0.85
______________

_____________________________
_____________________________
_____________________________

41,105
______________
11
______________
0.85
______________

Computation of Changes
41,105 x _____________
0.17
Old Computation (Prog. Change) ______________
41,105 x _____________
0.17
New Computation.............. ______________
Balance...

=
=

6,988
_______________
6,988
_______________
0
_______________

Old Computation (Adjustment)
New Computation..............
Balance...

______________ x _____________
______________ x _____________

=
=

_______________
_______________
_______________

Old Computation..............
New Computation..............
Balance...

______________ x _____________
______________ x _____________

=
=

_______________
_______________
_______________

Summary
Old Burden...................................................
Program Change...............................................
Adjustment...................................................
New Burden...................................................

6,988
_______________
0
_______________
_______________
6,988
_______________

Paperwork Reduction Act Notice
Time Per Response
0.17
Record Keeping............
Learning..................
Preparing.................
Sending...................

Notes:
No changes.

Average Hours
Per Response
______________
______________
______________
0.17
______________

Average Time
Per Response
___________________
___________________
___________________
0 hrs. , 10 min.
___________________