83-c

PAPERWORK REDUCTION ACT

CHANGE WORKSHEET

Agency/subagency

OMB Control Number

DHS-USCIS

0116
1615
___ ___
___ ___ - ___
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Enter only items that change
Current record

New record

Agency form number (s)

I-912

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

%

%

Total annual hours
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)
Total annualized cost requested
Difference
Explanation of difference
Program change
Adjustment
Other changes**

USCIS is adding a short informational NOTE to the Form Instructions document that does not increase the time or cost
burden on respondents.
Signature of Senior Official or designee:

john.r.ramsay@usci
s.dhs.gov

Digitally signed by
john.r.ramsay@uscis.dhs.gov
DN: cn=john.r.ramsay@uscis.dhs.gov
Date: 2018.03.09 11:59:43 -05'00'

** This form cannot be used to extend an expiration date.

OMB 83-C

Date:

For OIRA Use
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10/95