Limited Access Death Master File (LADMF) Certification Systems Safeguards Attestation Form

Limited Access Death Master File Subscriber Certification Form

Documents and Forms

Document Name Document Type
Form NTIS FM100 Limited Access Death Master File (LADMF) Certification Systems Safeguards Attestation Form Form
NTIS FM100 Limited Access Death Master File (LADMF) Certification S DMF Attestation Form Final to ROCIS 121914.pdf Form

Information Collection (IC) Details

IC Title:	Limited Access Death Master File (LADMF) Certification Systems Safeguards Attestation Form	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NTIS FM100	Limited Access Death Master File (LADMF) Certification Systems Safeguards Attestation Form	DMF Attestation 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 %

	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

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.