Form NTIS FM100 NTIS FM100 Limited Access Death Master File (LADMF) Certification S

National Technical
Information Service
5301 Shawnee Road
Alexandria, VA 22312

LIMITED ACCESS DEATH MASTER FILE
(LADMF) CERTIFICATION
SYSTEMS SAFEGUARDS ATTESTATION FORM

U N I T E D S TAT E S D E PA R T M E N T O F

COMMERCE

National Technical Information Service

TO BE COMPLETED BY AN ACCREDITED CERTIFICATION BODY (ACB).
NTIS FORM 100 | REVISION 0.1 DRAFT | DATED 11 DECEMBER 2014
FORM INSTRUCTIONS
Prior to being granted ACCESS TO LADMF DATA AND PRODUCTS, ALL PERSONS ARE REQUIRED
TO HAVE THIS FULLY COMPLETED FORM SUBMITTED BY AN ACB.
1. Review the requirements for accessing and using LADMF data and products at https://dmf.ntis.gov
2. Identify an ACB to assess your LADMF systems safeguards program implementation. Information on ACBs
may be found in 15 CFR Part 1110, Subpart F and at https://dmf.ntis.gov.
3. The ACB completes this form for a specific person* applying for LADMF certification. For additional
information on qualifying for LADMF access, see 15 CFR Part 1110.
4. The ACB submits this completed form directly to NTIS. NTIS will not accept NTIS FM100 from an applicant.
SECTION 1: APPLICANT INFORMATION
E-mail
Name
Company

Phone Number

NTIS Invoice/Order Confirmation Number for Processing Fee:
*Per 15 CFR Part 1110, a “person” includes a corporation, company, association, firm, partnership, society, joint
stock company, other private organization, or state or local government department or agency, or individual.
SECTION 2: INDEPENDENT ASSESSOR
Name
E-mail
Company

Phone Number

QUALIFICATION DESCRIPTION:
QUaLiFiCatioN ideNtiFierS:
SECTION 3: ASSESSMENT RESULTS
Assesment Date (no more than 3 years prior to date of applicant’s completed Form NTIS FM 161):
 An assessment of the applicant in Section 1 was completed that included the Controls in LADMF Certification Program
Publication 100, and based on findings the program is deemed satisfactory.
 An assessment of the applicant in Section 1 was completed that included the Controls in LADMF Certification Program
Publication 100, and unsatisfactory findings were identified. A remediation plan has been developed, and upon full plan
execution, the applicant’s LADMF program will be deemed satisfactory.
 An assessment of the applicant in Section 1 was completed that included the Controls in LADMF Certification Program
Publication 100, and based on findings the program is deemed unsatisfactory.
If this assessment was not conducted specifically or solely for the purpose of submission under 15 CFR Part 1110,
describe below the nature of the assessment upon which the assessment result in this Section 3 is based (note if additional
documentation is being submitted):_________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
U.S. Department of Commerce
National Technical Information Service
Alexandria, VA 22312

Form Number: NTIS FM100
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12/XX/2014

National Technical
Information Service
5301 Shawnee Road
Alexandria, VA 22312

LIMITED ACCESS DEATH MASTER FILE
(LADMF) CERTIFICATION
SYSTEMS SAFEGUARDS ATTESTATION FORM

U N I T E D S TAT E S D E PA R T M E N T O F

OMMERCE

National Technical Information Service

TO BE COMPLETED BY AN ACCREDITED CERTIFICATION BODY (ACB).
NTIS FORM 100 | REVISION 0.1 DRAFT | DATED 11 DECEMBER 2014
SECTION 4: ACB ATTESTATION
The undersigned Accredited Certification Body hereby attests that:
It is an independent third party certification body that is not “owned, managed, or controlled,” as defined
in 15 CFR §1110.501, by the applicant identified in Section 1.
It has read, understood and agrees to the regulations in 15 CFR Part 1110.
It is accredited to the following nationally or internationally recognized standard(s) for bodies providing
audit and certification of information security management systems (identify standard(s) and accrediting
body(ies)):

The scope of the accreditation identified above encompasses the safeguarding and security requirements set forth in 15 CFR Part
1110 and in LADMF Certification Program Publication 100.
A copy of its accreditation from the accreditation body identified above is submitted herewith.
It will cooperate in response to any request from NTIS to verify the accuracy, veracity, and/or completeness of
information received in connection with its assessment and this attestation.
By signing and submitting this form I attest that the ACB identified in Section 2 has conducted a full assessment of the LADMF
systems safeguards program of the applicant identified in Section 1, and that the findings are as specified in Section 3. The
undersigned hereby acknowledges that any willful false attestation or statement made herein is punishable under 18 U.S.C.
§1001 by fine or imprisonment of not more than five (5) years, or both.
I attest that I am authorized to sign this form on behalf of the ACB identified in Section 2.
Signature:_________________________________________________________________________________
Date:_______________________
Email to: [email protected]

Fax to: 703.605.6900

This collection of information contains Paperwork Reduction Act (PRA) requirements approved by the Office of Management and Budget (OMB). Notwithstanding any other provisions of the
law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the PRA unless that
collection of information displays a currently valid OMB control number. Public reporting burden for this collection is estimated to be X hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. Send comments regarding this burden
estimate or any aspect of this collection of information, including suggestions for reducing this burden, to the National Technical Information Service, Attn: John Hounsell, National Technical
Information Service, 5301 Shawnee Rd, Alexandria, VA 22313; [email protected], (703-605-6184).
OMB Control No.: 0692-XXX
Expiration Date: XX/XX/XXXX
U N I T E D S TAT E S D E PA R T M E N T O F

COMMERCE

National Technical Information Service

U.S. Department of Commerce
National Technical Information Service
Alexandria, VA 22312

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12/xx/2014