Burden

Burden Computation - Special Business Forms
Page 1 of 1

January 24, 2012

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

1099SA/
Distributions From an HSA, Archer MSA, or Medicare Advantage MSA
2008

Changes (+ -)

25,839
______________
9
______________
0.85
______________

_____________________________
_____________________________
_____________________________

2011
25,839
______________
9
______________
0.85
______________

Computation of Changes
25,839 x _____________
0.14
Old Computation (Prog. Change) ______________
25,839 x _____________
0.14
New Computation.............. ______________
Balance...

=
=

3,618
_______________
3,618
_______________
0
_______________

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

______________ x _____________
______________ x _____________

=
=

_______________
_______________
_______________

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

______________ x _____________
______________ x _____________

=
=

_______________
_______________
_______________

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

3,618
_______________
0
_______________
_______________
3,618
_______________

Paperwork Reduction Act Notice
Time Per Response
0.14
Record Keeping............
Learning..................
Preparing.................
Sending...................

Notes:
No change.

Average Hours
Per Response
______________
______________
0.14
______________
______________

Average Time
Per Response
___________________
___________________
0 hrs. , 08 min.
___________________
___________________