NTIS Proposed Certification Form for Access to the Death Master File

U.S. Department of Commerce
National Technical Information Service
Alexandria, VA 22312
National Technical Information Service
Limited Access Death Master File
(Derived from the Social Security Administration 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, and (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 the requirements of such section 6103(p)(4) as if such section applied
to the undersigned.
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: ___________________________________________________________
 Business Purpose: ___________________________________________________________________
 Law: ____________________________________________________________________________
 Governmental Rule: ________________________________________________________________
 Regulation: _______________________________________________________________________
 Fiduciary Duty: ___________________________________________________________________
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), (b) and (c) 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.
4. In making the certification in paragraph (3), the undersigned states the following (must check basis relied upon and
specify in the space provided):
 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:
 The undersigned will disclose information contained on the DMF with respect to a deceased 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: ______________________________________________
________________________________________________________________________________________________
 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: _______________________________________________________________
________________________________________________________________________________________________
 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: ___________________________________________________________
________________________________________________________________________________________________
National Technical Information Service
5301 Shawnee Rd
Alexandria, VA 22313
Email: [email protected]
Fax: 703.605.6900
Form Number: NTIS FM161
National Technical Information Service Limited Access Death Master File
(Derived from the Social Security Administration Death Master File)
Subscriber Certification Form Continued
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 NTIS 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 partnership, corporation, association, or public or private
organization, then the undersigned hereby represents and warrants that the undersigned is authorized to make this
certification on behalf of, and to bind, such partnership, corporation, association, or public or private organization.
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.
Authorized Name: ______________________________________________________________________________________
Authorized Signature: __________________________________________________________________________________
Name of Parnership, corporation, association, or public or private organization: _________________________________
______________________________________________________________________________________________________
Address: ______________________________________________________________________________________________
Phone Number: ______________________________________ Date: ___________________________________________
Death Master File Subscription Number: ________________ Email: __________________________________________
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; [email protected], (703-605-6184).
OMB Control No. 0692-XXXX
Expiration Date:
National Technical Information Service
5301 Shawnee Rd
Alexandria, VA 22313
Email: [email protected]
Fax: 703.605.6900
Form Number: NTIS FM161