NTIS Limited Access Death Master File Subscriber Certification Form

NTIS Limited Access Death Master File (LADMF) Subscriber Certification Form (Derived from the Social Security Administration's Death Master File)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0692-0013 can be found here:

Documents and Forms

Document Name Document Type
Form NTIS FM161 NTIS Limited Access Death Master File Subscriber Certification Form Form
NTIS FM161 NTIS Limited Access Death Master File Subscriber Certifi 0692-0013-NTIS-LADMF-SubscriberCertificationForm-NTIS FM161.pdf Form
NTIS FM 161 NTIS Limited Access Death Master File Certification Form 2019 Fillable dmf-certification form nonsubstantive change 080219 clean copy.docx Form
2019 Fillable dmf-certification form Nonsubstantive change 080219 with track changes.docx NTIS Limited Access Death Master File Certification Form with Track Changes IC Document

Information Collection (IC) Details

IC Title:	NTIS Limited Access Death Master File Subscriber Certification Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NTIS FM161	NTIS Limited Access Death Master File Subscriber Certification Form	0692-0013-NTIS-LADMF-SubscriberCertificationForm-NTIS FM161.pdf		Yes	Yes	Fillable Fileable
Form	NTIS FM 161	NTIS Limited Access Death Master File Certification Form	2019 Fillable dmf-certification form nonsubstantive change 080219 clean copy.docx		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: 560	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	560	560
Annual IC Time Burden (Hours)	1,400	1,400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
NTIS Limited Access Death Master File Certification Form with Track Changes	2019 Fillable dmf-certification form Nonsubstantive change 080219 with track changes.docx	08/05/2019

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