Form NTIS FM161 NTIS FM161 Limited Access Death Master File Certification Form

Check applicable box:

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

First time certification
Renewal of certification

Limited Access Death Master File
Certification Form
1.

2.

The undersigned hereby certifies that access to the NTIS Limited Access Death Master File, (LADMF) (as defined in
15 CFR § 1110.2) is appropriate because the undersigned (a) has (i) a legitimate fraud prevention interest, or (ii) a
legitimate business purpose pursuant to a law, governmental rule, regulation, or fiduciary duty, (b) has systems
facilities, and procedures in place to safeguard such information, and experience in maintaining the confidentiality,
security, and appropriate use of such information, pursuant to requirements reasonably similar to the requirements of
section 6103(p)(4) of the Internal Revenue Code of 1986, and (c) agrees to satisfy such similar requirements.
In making the certification in paragraph (1) above, the undersigned states the following specific basis (must
check each basis relied upon and must specify):
 Fraud Prevention Interest (explain what kind of fraud is being prevented):

 Business Purpose:

 Law (cite the Law, e.g., 000 U.S.C. 0000, or applicable state or local law):

 Governmental

Rule (cite the Rule):

 Regulation (cite the Regulation):



Fiduciary Duty

:

3. The undersigned further certifies that with respect to LADMF of any deceased individual at any time during the
three calendar year period beginning on the date of the individual’s death, which is received by the undersigned, the
undersigned shall not: (i) disclose any information contained on the LADMF with respect to any deceased individual
to any person other than a person who meets the requirements of each of (a), (b), and (c) in paragraph (1); (ii)
disclose any information contained on the LADMF with respect to any deceased individual to any person who uses
the information for any purpose other than a legitimate fraud prevention interest or a legitimate business purpose
pursuant to a law, governmental rule, regulation, or fiduciary duty; (iii) disclose any information contained on the
LADMF with respect to any deceased individual to any person who further discloses the information to any person
other than a person who meets the requirements of each of (a) and (b) in paragraph (1); or (iv) use any information
contained on the LADMF with respect to any deceased individual for any purpose other than a legitimate fraud
prevention interest or a legitimate business purpose pursuant to a law, governmental rule, regulation or fiduciary duty.
National Technical Information Service
Email: [email protected]
5301 Shawnee Rd
Fax: 703.605.6900
Alexandria, VA 22312-2312
Form Number: NTIS FM161

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

Limited Access Death Master File
Certification Form Continued
4. In making the certification in paragraph (3), the undersigned states the following (must check basis relied upon and
specify in the space provided):
 A The undersigned shall not disclose any information contained on the DMF with respect to any deceased individual at any time during the three-calendar-year period beginning on the date of the individual’s death,
which is received by the undersigned, to any other person; or
 B The undersigned will disclose information contained on the DMF with respect to an individual during the
three-calendar-year period beginning on the date of the individual’s death, which is received by the undersigned, to another person(s) in the following manner only (for a disclosure to another person other than a
Certified Person as defined in 15 CFR § 1110.2, must also check and complete i. & ii. below)

 i. The undersigned shall ensure compliance by such other person(s) with the requirements of each of (i),

(ii) and (iii) of the paragraph above as follows:
 ii. The undersigned shall ensure that such other person(s) is made aware that the penalty provisions of
15 CFR § 1110.200 apply to such person(s) as follows:

5. The undersigned acknowledges that failure to comply with the provisions of paragraph (3) may subject the undersigned to penalties under 15 CFR §1110.200 of $1,000 for each disclosure or use, up to a maximum of $250,000 in
penalties per calendar year.
6. The undersigned hereby consents to the performance by a third party auditor of periodic and unscheduled audits of
the undersigned to determine the compliance by the undersigned with the certifications made herein.
7. If the undersigned makes this certification on behalf of a corporation, company, association, firm, partnership, society,
joint stock company, other private organization, or state or local government department or agency, then the undersigned hereby represents and warrants that the undersigned is authorized to make this certification on behalf of, and
to bind, such corporation, company, association, firm, partnership, society, joint stock company, other private
organization, or state or local government department or agency.
8. The undersigned hereby declares that all certifications and statements made herein of the undersigned’s own knowledge are true and that all certifications and statements made on information and belief are believed to be true; and
further that these certifications and statements were made with the knowledge that willful false statements and the
like so made are punishable by fine or imprisonment, or both, under 18 U.S.C. §1001. The undersigned hereby acknowledges that any willful false certification 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.
9. The undersigned acknowledges that, if approved, their Certification will be effective on the effective date indicated
in the approval email from NTIS and will expire one year thereafter on the expiration date indicated in the same
email.
National Technical Information Service
5301 Shawnee Rd
Alexandria, VA 22312-2312

Email: [email protected]
Fax: 703.605.6900
Form Number: NTIS FM161

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

Limited Access Death Master File
Certification Form Continued
Authorized Name:
Authorized Signature:
Name of corporation, company, association, firm, partnership, society, joint stock company, other private organization, or state or local government department or agency:

Address:
Phone Number:

Date:

Death Master File Subscription:

Email:

NTIS Customer Number (Customer Number assigned to you by NTIS if applicable):
State Incorporation/Registration Number:

EIN (if applicable):

URL (if applicable):

Check if applicable:
We are a state or local government department or agency.
We are not submitting a written attestation under 15 CFR §1110.101 (b) because we are renewing our certification and;
have submitted a written attestation within three years of the date of this application.
were subject to a satisfactory audit under 15 CFR §1110.201 within three years of the date
of this application.
ment 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 2.5 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: Daniel Ramsey, National Technical Information
Service, 5301 Shawnee Rd, Alexandria, VA 22313; [email protected], (703-605-6703).
OMB Control Number 0692-0013
Expiration Date January 31, 2020
03.20a082714v30

National Technical Information Service
5301 Shawnee Rd
Alexandria, VA 22312-2312

Email: [email protected]
Fax: 703.605.6900
Form Number: NTIS FM161