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pdfBurden Computation - Special Business Forms
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October 27, 2014
Product:
Description:
Variables
Responses.......
Line Items......
Forms Prepared..
5498SA/
HSA, Archer MSA, or Medicare Advantage MSA Information
2011
Changes (+ -)
2014
52,217
______________
11
______________
0.85
______________
_____________________________
_____________________________
_____________________________
9,167
______________
11
______________
0.85
______________
Computation of Changes
9,167 x _____________
0.17
Old Computation (Prog. Change) ______________
9,167 x _____________
0.17
New Computation.............. ______________
Balance...
=
=
1,559
_______________
1,559
_______________
0
_______________
Old Computation (Adjustment)
New Computation..............
Balance...
52,217 x _____________
0.17
______________
______________
9,167 x _____________
0.17
=
=
8,877
_______________
_______________
1,559
-7,318
_______________
Old Computation..............
New Computation..............
Balance...
______________ x _____________
______________ x _____________
=
=
_______________
_______________
_______________
Summary
Old Burden...................................................
Program Change...............................................
Adjustment...................................................
New Burden...................................................
8,877
_______________
0
_______________
-7,318
_______________
1,559
_______________
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.
___________________
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