Form NTIS FM161 NTIS FM161 Limited Access Death Master File Subscriber Certificatio

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

Limited Access Death Master File
Subscriber Certification Form
1. The undersigned hereby certifies that access to the NTIS Limited Access DMF (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 similar to the requirements of section 6103(p)(4) of the Internal Revenue Code of 1986, and (c) agrees to satisfy such similar requirements.
2. 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 (explain what the fiduciary duty is):

3. The undersigned further certifies that with respect to DMF of any deceased individual at any time during the threecalendar-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 DMF 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 DMF 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 DMF 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 DMF 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
5301 Shawnee Rd
Alexandria, VA 22312-2312

Page 1 of 4

Email: DMFCERT@NTIS.GOV
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
Subscriber 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 aknowledges 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

Page 2 of 4

Email: DMFCERT@NTIS.GOV
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
Subscriber 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 Number:

Email:

URL (if applicable):
NTIS Customer Number (if applicable):

(Customer Number assigned to you by NTIS)

Dun and Bradstreet Number (if applicable):
Authorized Contact Person:
(if different than above)

Phone Number:
Email:

(if different than above)

NTIS Invoice/Order Confirmation Number for Processing Fee:
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 2 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; jhounsell@ntis.gov, (703-605-6184).
OMB Control No.
Expiration Date: XX/XX/2015
03.20a082714v30

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

Page 3 of 4

Email: DMFCERT@NTIS.GOV
Fax: 703.605.6900
Form Number: NTIS FM161

Additional Notes page.
Please specify the number and subsection :at the beginning of each new entry.

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

Page 4 of 4

Email: DMFCERT@NTIS.GOV
Fax: 703.605.6900
Form Number: NTIS FM161