NTIS FM100A NTIS Limited Access Death Master File (LADMF) Accredited

National Technical
Information Service
5301 Shawnee Road
Alexandria, VA 22312

LIMITED ACCESS DEATH MASTER FILE (LADMF)
ACCREDITED CONFORMITY ASSESSMENT BODY
SYSTEMS SAFEGUARDS ATTESTATION FORM

TO BE COMPLETED BY AN ACCREDITED CONFORMITY ASSESSEMENT BODY (ACAB).
NTIS FM 100 A | REVISION 0.2 | DATED 11 OCTOBER 2016

FORM INSTRUCTIONS FOR APPLICANTS
PRIOR TO BEING GRANTED ACCESS TO LADMF DATA AND PRODUCTS FROM NTIS, ALL PERSONS ARE
REQUIRED TO HAVE THIS FULLY COMPLETED FORM SUBMITTED BY AN ACAB. STATE AND LOCAL
GOVERNMENT DEPARTMENTS AND AGENCIES RELYING ON ATTESTATIONS FROM STATE OR LOCAL
GOVERNMENT AUDITORS GENERAL OR INSPECTORS GENERAL SHOULD USE FORM NTIS FM 100B.
1. Review the requirements for accessing and using LADMF data and products at https://dmf.ntis.gov.
2. Identify an ACAB to assess your LADMF systems safeguards program implementation.
3. The ACAB submits this completed form directly to NTIS. NTIS will not accept Form NTIS FM100A directly
from an applicant.
SECTION 1: APPLICANT INFORMATION
NAME OF APPLICANT ORGANIZATION

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: INDEPENDENT OR FIREWALLED ACAB
NAME OF ASSESSOR
E-MAIL OF ASSESSOR
COMPANY

PHONE NUMBER

SECTION 3: ASSESSMENT RESULTS
An assessment of the applicant named in Section 1 was completed using ___________________________ [fill in
applicable standard(s)] 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
Page 1 of 2
Alexandria, VA 22312

Form Number: NTIS FM100A
10/11/2016

(LIMITED ACCESS DEATH MASTER FILE
(LADMF) CERTIFICATION ACCREDITED CONFORMITY
ASSESSMENT BODY
SYSTEMS SAFEGUARDS ATTESTATION FORM
TO BE COMPLETED BY AN ACCREDITED CONFORMITY ASSESSEMENT BODY (ACAB).

National Technical
Information Service
5301 Shawnee Road
Alexandria, VA 22312

NTIS FM 100 A | REVISION 0.2 | DATED 11 OCTOBER 2016
SECTION 4: ACAB ATTESTATION

The undersigned Accredited Conformity Assessment Body hereby attests that:
1. It is either:
An independent third party accredited conformity assessment body that is not “owned, managed, or
controlled,” as defined in 15 CFR §1110.501, by the applicant identified in Section 1, OR
A firewalled accredited conformity assessment body whose LADMF ACAB Application for Firewalled
Status has been accepted by NTIS.
2. It has read and understands the regulations in 15 CFR Part 1110.
3. It is accredited to the following nationally or internationally recognized standard(s) for bodies providing audit
and assessment of information security management systems (identify standard(s) and accrediting body(ies)):

4. The scope of the accreditation identified above encompasses the information safeguarding and security
requirements set forth in 15 CFR Part 1110.
5. 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 ACAB identified in
Section 2, that the ACAB identified in Section 2 has conducted an 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: Daniel Ramsey, National Technical Information Service, 5301 Shawnee Rd, Alexandria, VA 22312; [email protected]
(703-605-6703).
OMB Control No.:
0692-0016 Expiration
Date: 10/31/2023
U.S. Department of Commerce
National Technical Information Service
Alexandria, VA 22312
Page 2 of 2

Form Number: NTIS FM100A
10/11/2016