NTIS FM 100B NTIS Limited Access Death Master File (LADMF) State or L

National Technical
Information Service
5301 Shawnee Road
Alexandria, VA 22312

LIMITED ACCESS DEATH MASTER FILE (LADMF)
STATE OR LOCAL GOVERNMENT AUDITOR
GENERAL (AG) OR INSPECTOR GENERAL (IG)
SYSTEMS SAFEGUARDS ATTESTATION FORM

TO BE COMPLETED BY A STATE OR LOCAL GOVERNMENT AUDITOR GENERAL OR
INSPECTOR GENERAL.
NTIS FM 100B | REVISION 0.2 | DATED 11 OCTOBER 2016
FORM INSTRUCTIONS FOR STATE AND LOCAL GOVERNMENT
APPLICANTS
PRIOR TO BEING GRANTED ACCESS TO LADMF DATA AND PRODUCTS FROM NTIS, ANY STATE OR
LOCAL GOVERNMENT DEPARTMENT OR AGENCY RELYING ON AN ATTESTATION FROM A STATE OR
LOCAL AG OR IG IS REQUIRED TO HAVE THIS FULLY COMPLETED FORM SUBMITTED BY THE AG OR IG.
1. Review the requirements for accessing and using LADMF data and products at https://dmf.ntis.gov.
2. The state or local AG or IG completes this form for a specific person* applying for LADMF certification.
3. The state or local AG or IG submits this completed form directly to NTIS. NTIS will not accept Form NTIS
FM100B directly from an applicant.
SECTION 1: STATE OR LOCAL GOVERNMENT APPLICANT
INFORMATION
NAME OF APPLICANT STATE OR LOCAL GOVERNMENT DEPARTMENT OR AGENCY

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: STATE OR LOCAL GOVERNMENT AUDITOR
GENERAL OR INSPECTOR GENERAL
NAME OF ASSESSOR
E-MAIL OF ASSESSOR
AG/IG OFFICE

PHONE NUMBER

SECTION 3: ASSESSMENT RESULTS
An assessment of the state or local government applicant named in Section 1 was completed and based on the
findings the applicant has systems, facilities and procedures in place to safeguard LADMF information as required
by 15 CFR 1110.102(a)(2). This assessment was conducted on _________ [enter date of assessment], which is
no more than 3 years prior to the date of the applicant’s completed Form NTIS FM 161.

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

Page 1 of 2

Form Number: NTIS FM100B
10/11/2016

LIMITED ACCESS DEATH MASTER FILE (LADMF)
CERTIFICATION FOR STATE OR LOCAL GOVERNMENT
AUDITOR GENERAL (AG) OR INSPECTOR GENERAL (IG)
SYSTEMS SAFEGUARDS ATTESTATION FORM
TO BE COMPLETED BY A STATE OR LOCAL GOVERNMENT AUDITOR GENERAL OR
INSPECTOR GENERAL.

National Technical
Information Service
5301 Shawnee Road
Alexandria, VA 22312

NTIS FM 100B | REVISION 0.2 | DATED 11 OCTOBER 2016
SECTION 4: STATE OR LOCAL GOVERNMENT AG OR
IG ATTESTATION
The undersigned State or Local Auditor General or Inspector General hereby attests that:
1.

It has read and understands the regulations in 15 CFR Part 1110.

2.

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 I am authorized to sign this form on behalf of the State or Local
Government AG or IG identified in Section 2, that the State or Local Government AG or IG 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 results are as specified in Section 3. I hereby acknowledge 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.
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 3 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.: 0692-0016
Expiration Date: 07/31/2017

U.S. Department of Commerce
National Technical Information Service
Alexandria, VA 22312
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Form Number: NTIS FM100B
10/11/2016