83c

PAPERWORK REDUCTION ACT

CHANGE WORKSHEET

Agency/subagency

OMB Control Number

DHS/USCIS

0043
1615
___ ___
___ ___ - ___
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Enter only items that change
Current record

New record

Agency form number (s)

Form I-821

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**

The fee for USCIS Form I-821 will change depending on the respondents' status as a result of the final rule titled U.S.
Citizenship and Immigration Services Fee Schedule and Changes to Certain Other Immigration Benefits Requests,
1615-AC18. Other changes to this information collection are listed in the Table of Changes submitted to OIRA as part of the
rule package.
Signature of Senior Official or designee:
Date:
For OIRA Use
___________________________________
___________________________________
7/20/2020
** This form cannot be used to extend an expiration date.

OMB 83-C

10/95