Information Collection

Limited Access Death Master File Subscriber Certification Form

IC 214345 under ICR 201408-0692-003 · OMB 0692-0014.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NTIS FM161 Limited Access Death Master File Subscriber Certification Form	Form
NTIS FM161 Limited Access Death Master File Subscriber Certificatio DMF Certification Form Final to Rocis 121914.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NTIS FM161	Limited Access Death Master File Subscriber Certification Form	DMF Certification Form Final to Rocis 121914.pdf		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 550

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	550	550
Annual IC Time Burden (Hours)	1,100	1,100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.