Signed OMB 83-C Form (2502-0586)

Agency/subagency

PAPERWORK REDUCTION ACT
CHANGE WORKSHEET

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Agency form number (s)
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OMB Control Number
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Enter only items that change
Current record

New record
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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

Other changes**

Program change
Adjustment

Signature of Senior Official or designee:

Date:
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** This form cannot be used to extend an expiration date.
OMB 83-C

For OIRA Use
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10/95