Burden

Burden Computation - Special Business Forms
Page 1 of 1

October 19, 2011

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

5498SA/
HSA, Archer MSA, or Medicare Advantage MSA Information
2008

Changes (+ -)

2011

41,105
______________
11
______________
0.85
______________

+11,112
_____________________________
_____________________________
_____________________________

52,217
______________
11
______________
0.85
______________

Computation of Changes
52,217 x _____________
0.17
Old Computation (Prog. Change) ______________
52,217 x _____________
0.17
New Computation.............. ______________
Balance...

=
=

8,877
_______________
8,877
_______________
0
_______________

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

41,105 x _____________
0.17
______________
______________
52,217 x _____________
0.17

=
=

6,988
_______________
_______________
8,877
+1,889
_______________

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

______________ x _____________
______________ x _____________

=
=

_______________
_______________
_______________

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

6,988
_______________
0
_______________
+1,889
_______________
8,877
_______________

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

Notes:

Average Hours
Per Response
______________
______________
______________
0.17
______________

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