2019 Fillable DMF-certification form revised 080219 with track changes

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

Limited Access Death Master File

Check applicable box: First time certification

Renewal of certification

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., 000 U.S.C. 0000, or applicable state or local law):

• Governmental Rule (cite the Rule):

• Regulation (cite the Regulation):

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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.

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):

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A The undersigned shall not disclose any information contained on the DMF with respect to any deceased in- dividual 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

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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 under- signed, 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 under- signed 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 under- signed 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 organiza- tion, 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 knowl- edge 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 ac- knowledges 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.

Certification Form Continued

Authorized Name:

Authorized Signature:

Name of corporation, company, association, firm, partnership, society, joint stock com- pany, other private organization, or state or local government department or agency:

Address:

Phone Number: Date:

Death Master File Subscription/License Number: 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.

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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 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 Number 0692-0013 Expiration Date January 31, 2020

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