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

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

Check applicable box:
 First time certification
 Renewal of certification

Limited Access Death Master File
Subscriber Certification Form
1. 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.
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., 00 U.S.C. 0000, or applicable state or local law):

 Governmental

Rule (cite the Rule):

 Regulation (cite the Regulation, e.g., 00 C.F.R. 0000, or applicable state or local regulation):

 Fiduciary

Duty (explain what the fiduciary duty is):

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
5301 Shawnee Rd
Alexandria, VA 22312-2312

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

Limited Access Death Master File
Subscriber Certification Form
Page 2 of 4
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 LADMF 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 LADMF 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 paragraph 3. 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: DMFCERT@NTIS.GOV
Fax: 703.605.6900
Form Number: NTIS FM161

Limited Access Death Master File
Subscriber Certification Form
Page 3 of 4
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 (Customer Number assigned to you by NTIS if applicable):
State Incorporation/Registration Number

EIN (if applicable):

Authorized Contact Person:
Phone Number:

(if different than above)

Email:

(if different than above)

Check if applicable:
We are a state or local government department or agency.
We are submitting a copy of our current attestation under15 CFR §1110.101(b) because we are renewing our
certification and;
have submitted this attestation within three years of the date of this application, or
were subject to a satisfactory audit under 15 CFR §1110.201 within three years of the
date of this application.

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

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

Limited Access Death Master File
Subscriber Certification Form
Page 4 of 4
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 2.5 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: John
Hounsell, National Technical Information Service, 5301 Shawnee Rd, Alexandria, VA 22313; jhounsell@ntis.gov,
(703-605-6184).
OMB Control No. 0692-0013
Expiration Date: XX/XX/XXXX
03.20a082714v30

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

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