Information Collection

NTIS Limited Access Death Master File Subscriber Certification Form

IC 224474 under ICR 202603-0692-001 · OMB 0692-0013.

Documents and Forms

Document Name Document Type
Form FM 101 Application Form for Firewalled Status NTIS Limited Access Death Master File Subscriber Certification Form Form
Form FM 161 LADMF Certification Form NTIS Limited Access Death Master File Subscriber Certification Form Form
Form Form 100A Safeguards Attestation Froms NTIS Limited Access Death Master File Subscriber Certification Form Form
Form Form 100B Systems Safeguards Attetations for State and Local AGs and IGS NTIS Limited Access Death Master File Subscriber Certification Form Form
FM 101 Application Form for Firewalled Status FM 101_LADMF ACAB Application Form for Firewalled Status Fillable Form_updated 10.3.2025.pdf Form
FM 161 LADMF Certification Form FM 161_Limited Access Death Master File Certification Fillable Form_updated 10.3.2025.pdf Form
Form 100A Safeguards Attestation Froms FM 100A_Accredited Conformity Assessment Body Systems Safeguards Attestation Fillable Form_updated 10.3.2025.pdf Form
Form 100B Systems Safeguards Attetations for State and Local AGs a Systems Safeguards Attestations for State and Local AGs and IGs - 10 2025.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	FM 101	Application Form for Firewalled Status	FM 101_LADMF ACAB Application Form for Firewalled Status Fillable Form_updated 10.3.2025.pdf	Yes	Yes	Fillable Fileable
Form	FM 161	LADMF Certification Form	FM 161_Limited Access Death Master File Certification Fillable Form_updated 10.3.2025.pdf	Yes	Yes	Fillable Fileable
Form	Form 100A	Safeguards Attestation Froms	FM 100A_Accredited Conformity Assessment Body Systems Safeguards Attestation Fillable Form_updated 10.3.2025.pdf	Yes	Yes	Fillable Fileable
Form	Form 100B	Systems Safeguards Attetations for State and Local AGs and IGS	Systems Safeguards Attestations for State and Local AGs and IGs - 10 2025.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: 260	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	260	260
Annual IC Time Burden (Hours)	780	780
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.

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