DD2875CAVAF.pdf

SYSTEM AUTHORIZATION ACCESS REQUEST (SAAR)

PRIVACY ACT STATEMENT

Executive Order 10450, 9397; and Public Law 99-474, the Computer Fraud and Abuse Act.

To record names, signatures, and other identifiers for the purpose of validating the trustworthiness of individuals requesting access to Department of Defense (DoD) systems and information. NOTE: Records may be maintained in both electronic and/or paper form.

None.

Disclosure of this information is voluntary; however, failure to provide the requested information may impede, delay or prevent further processing of this request.

TYPE OF REQUEST

INITIAL MODIFICATION DEACTIVATE

2. ORGANIZATION

3. OFFICE SYMBOL/DEPARTMENT

8. CITIZENSHIP

6. JOB TITLE AND GRADE/RANK

AUTHORIZED PRIVILEGED

UNCLASSIFIED

I certify that this user requires access as requested.

7. OFFICIAL MAILING ADDRESS

5. OFFICIAL E-MAIL ADDRESS

PREVIOUS EDITION IS OBSOLETE.

USER ID

9. DESIGNATION OF PERSON

OTHER

AUTHORITY:

PRINCIPAL PURPOSE:

ROUTINE USES:

DISCLOSURE:

US FN

OTHER

MILITARY CIVILIAN

CONTRACTOR

APD PE v1.00

I have completed Annual Information Awareness Training.

DATE (YYYYMMDD)

PART I (To be completed by Requestor)

1. NAME (Last, First, Middle Initial)

4. PHONE (DSN or Commercial)

PART II - ENDORSEMENT OF ACCESS BY INFORMATION OWNER, USER SUPERVISOR OR GOVERNMENT SPONSOR (If individual is a contractor - provide company name, contract number, and date of contract expiration in Block 1 6 .)

16 a. ACCESS EXPIRATION DATE (Contractors must specify Company Name, Contract Number, Expiration Date. Use Block 27 if needed.)

18. SUPERVISOR'S SIGNATURE17. SUPERVISOR'S NAME (Print Name) 19. DATE (YYYYMMDD)

14. TYPE OF ACCESS REQUIRED:

15. USER REQUIRES ACCESS TO: CLASSIFIED (Specify category)

13. JUSTIFICATION FOR ACCESS

16. VERIFICATION OF NEED TO KNOW

22. SIGNATURE OF IAO OR APPOINTEE

20. SUPERVISOR'S ORGANIZATION/DEPARTMENT 20 b. PHONE NUMBER

2 5. DATE (YYYYMMDD)

. SIGNATURE OF INFORMATION OWNER/OPR

23. ORGANIZATION/DEPARTMENT

21a. PHONE NUMBER 21b. DATE (YYYYMMDD)

DD FORM 2875, AUG 2009

SYSTEM NAME (Platform or Applications) LOCATION (Physical Location of System)

24. PHONE NUMBER

20 a. SUPERVISOR'S E-MAIL ADDRESS

11 . USER SIGNATURE 12 . DATE (YYYYMMDD)

10. IA TRAINING AND AWARENESS CERTIFICATION REQUIREMENTS (Complete as required for user or functional level access.)

DATE (YYYYMMDD)

PART IV - COMPLETION BY AUTHORIZED STAFF PREPARING ACCOUNT INFORMATION

(YYYYMMDD)

SYSTEM

DOMAIN

SERVER

APPLICATION

DIRECTORIES

FILES

DATASETS

TITLE: ACCOUNT CODE

DATE REVALIDATED

(YYYYMMDD)

PART III - SECURITY MANAGER VALIDATES THE BACKGROUND INVESTIGATION OR CLEARANCE INFORMATION

LEVEL I LEVEL II LEVEL III

TELEPHONE NUMBER

DD FORM 2875 (BACK), AUG 2009

PROCESSED BY (Print name and sign)DATE PROCESSED DATE (YYYYMMDD)

27. OPTIONAL INFORMATION (Additional information)

REVALIDATED BY (Print name and sign) DATE (YYYYMMDD)

28b. CLEARANCE LEVEL

28. TYPE OF INVESTIGATION 28a. DATE OF INVESTIGATION (YYYYMMDD)

28c. IT LEVEL DESIGNATION

31. SECURITY MANAGER SIGNATURE29. VERIFIED BY (Print name) 32. DATE (YYYYMMDD)

26. NAME (Last, First, Middle Initial)

30 . SECURITY MANAGER

establishing or modifying their USER ID.

(1) Name. The last name, first name, and middle initial of the user.

(2) Organization. The user's current organization (i.e. DISA, SDI, DoD and government agency or commercial firm).

(3) Office Symbol/Department. The office symbol within the current organization (i.e. SDI).

(4) Telephone Number/DSN. The Defense Switching Network (DSN) phone number of the user. If DSN is unavailable, indicate commercial number.

(5)Official E-mail Address. The user's official e-mail address.

(6) Job Title/Grade/Rank. The civilian job title (Example: Systems Analyst, GS-14, Pay Clerk, GS-5)/military rank (COL, United States Army, CMSgt, USAF) or "CONT" if user is a contractor.

(7) Official Mailing Address. The user's official mailing address.

(8) Citizenship (US, Foreign National, or Other).

(9) Designation of Person (Military, Civilian, Contractor).

indicate if he/she has completed the Annual Information Awareness Training and the date.

understanding that they are responsible and accountable for their password and access to the system(s).

user's Supervisor or the Government Sponsor.

establishment of an initial USER ID. Provide appropriate information if the USER ID or access to the current USER ID is modified.

(Authorized - Individual with normal access. Privileged - Those with privilege to amend or change system configuration, parameters, or settings.)

Specify category.

access as requested.

date if less than 1 year.

prints his/her name to indicate that the above information has been verified and that access is required.

endorser or his/her representative.

and department.

INSTRUCTIONS

The prescribing document is as issued by using DoD Component.

appointee responsible for approving access to the system being requested.

2875.

Signature of the IAO or Appointee of the office responsible for approving access to the system being requested.

information, as required.

investigation (i.e., NAC, NACI, or SSBI).

(Secret or Top Secret).

or Level III).

name to indicate that the above clearance and investigation information has been verified.

the Security Manager or his/her representative.

representative indicates that the above clearance and investigation information has been verified.

or his/her representative.

by either the DoD, functional activity, or the customer with approval of the DoD. This information will specifically identify the access required by the user.

E. DISPOSITION OF FORM:

TRANSMISSION: Form may be electronically transmitted, faxed, or mailed. Adding a password to this form makes it a minimum of "FOR OFFICIAL USE ONLY" and must be protected as such.

FILING: Original SAAR, with original signatures in Parts I, II, and III, must be maintained on file for one year after termination of user's account. File may be maintained by the DoD or by the Customer's IAO. Recommend file be maintained by IAO adding the user to the system.

A. PART I: The following information is provided by the user when

(10) IA Training and Awareness Certification Requirements. User must

(11 ) User's Signature. User must sign the DD Form 2875 with the

(12 ) Date. The date that the user signs the form.

B. PART II: The information below requires the endorsement from the

(13 ). Justification for Access. A brief statement is required to justify

(14 ) Type of Access Required: Place an "X" in the appropriate box.

(15 ) User Requires Access To: Place an "X" in the appropriate box.

(16 ) Verification of Need to Know. To verify that the user requires

(16 a) Expiration Date for Access. The user must specify expiration

(17 ) Supervisor's Name (Print Name). The supervisor or representative

(18 ) Supervisor's Signature. Supervisor's signature is required by the

(19 ) Date. Date supervisor signs the form.

( 20 ) Supervisor's Organization/Department. Supervisor's organization

( 20 a) E-mail Address. Supervisor's e-mail address.

( 20 b) Phone Number. Supervisor's telephone number.

DD FORM 2875 INSTRUCTIONS, AUG 2009

(2 1) Signature of Information Owner/OPR. Signature of the functional

(2 1a) Phone Number. Functional appointee telephone number.

(2 1b) Date. The date the functional appointee signs the DD Form

(2 2) Signature of Information Assurance Officer (IAO) or Appointee.

(2 3) Organization/Department. IAO's organization and department.

(2 4) Phone Number. IAO's telephone number.

(2 5) Date. The date IAO signs the DD Form 2875.

(2 7) Optional Information. This item is intended to add additional

C. PART III: Certification of Background Investigation or Clearance.

(2 8) Type of Investigation. The user's last type of background

(2 8a) Date of Investigation. Date of last investigation.

(2 8b) Clearance Level. The user's current security clearance level

(2 8c) IT Level Designation. The user's IT designation (Level I, Level II, (2 9) Verified By. The Security Manager or representative prints his/her

( 30) Security Manager Telephone Number. The telephone number of

(31 ) Security Manager Signature. The Security Manager or his/her

(3 2) Date. The date that the form was signed by the Security Manager

D. PART IV: This information is site specific and can be customized