Form2875.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 Social Security Numbers 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

DATE (YYYYMMDD)

PART I (To be completed by Requestor)

1. NAME (Last, First, Middle Initial) 2. SOCIAL SECURITY NUMBER

3. ORGANIZATION 4. OFFICE SYMBOL/DEPARTMENT

9. CITIZENSHIP

7. JOB TITLE AND GRADE/RANK

5. PHONE (DSN or Commercial)

I accept the responsibility for the information and DoD system to which I am granted access and will not exceed my authorized level of system access. I understand that my access may be revoked or terminated for non-compliance with DoD security policies. I accept responsibility to safeguard the information contained in these systems from unauthorized or inadvertent modification, disclosure, destruction, and use. I understand and accept that my use of the system may be monitored as part of managing the system, protecting against unauthorized access and verifying security problems. I agree to notify the appropriate organization that issued my account(s) when access is no longer required.

11. USER SIGNATURE 12. DATE (YYYYMMDD)

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 16.)

16a. 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:

AUTHORIZED PRIVILEGED

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

13. JUSTIFICATION FOR ACCESS

16. VERIFICATION OF NEED TO KNOW

I certify that this user requires access as requested.

22. SIGNATURE OF IAO OR APPOINTEE

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

25. DATE (YYYYMMDD)

21. SIGNATURE OF INFORMATION OWNER/OPR

23. ORGANIZATION/DEPARTMENT

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

8. OFFICIAL MAILING ADDRESS

6. OFFICIAL E-MAIL ADDRESS

DD FORM 2875, APR 2005 PREVIOUS EDITION IS OBSOLETE.

USER ID

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

10. DESIGNATION OF PERSON

OTHER

24. PHONE NUMBER

AUTHORITY:

PRINCIPAL PURPOSE:

ROUTINE USES:

DISCLOSURE:

USER AGREEMENT

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

I have completed Annual Information Awareness Training. DATE (YYYYMMDD)

20a. SUPERVISOR'S E-MAIL ADDRESS

US FN

OTHER

MILITARY CIVILIAN

CONTRACTOR

DD FORM 2875 (BACK), APR 2005

PART IV - COMPLETION BY AUTHORIZED STAFF PREPARING ACCOUNT INFORMATION

PROCESSED BY (Print name and sign)DATE PROCESSED

(YYYYMMDD)

DATE (YYYYMMDD)

27. OPTIONAL INFORMATION (Additional information)

SYSTEM

DOMAIN

SERVER

APPLICATION

DIRECTORIES

FILES

DATASETS

TITLE: ACCOUNT CODE

REVALIDATED BY (Print name and sign)DATE REVALIDATED

(YYYYMMDD)

DATE (YYYYMMDD)

28b. CLEARANCE LEVEL

28. TYPE OF INVESTIGATION

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

28a. DATE OF INVESTIGATION (YYYYMMDD)

28c. IT LEVEL DESIGNATION

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

26a. NAME (Last, First, Middle Initial) 26b. SOCIAL SECURITY NUMBER

LEVEL I LEVEL II LEVEL III

30. SECURITY MANAGER

TELEPHONE NUMBER

A. PART I: The following information is provided by the user when establishing or modifying their USER ID.

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

(2) Social Security Number. The social security number of user.

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

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

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

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

(7) 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.

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

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

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

IA Training and Awareness Certification Requirements. User must indicate if he/she has completed the Annual Information Awareness Training and the date.

(11) User's Signature. User must sign the DD Form 2875 with the understanding that they are responsible and accountable for their password and access to the system(s).

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

B. PART II: The information below requires the endorsement from the user's Supervisor or the Government Sponsor.

(13). Justification for Access. A brief statement is required to justify establishment of an initial USER ID. Provide appropriate information if the USER ID or access to the current USER ID is modified.

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

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

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

Specify category.

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

(16a) Expiration Date for Access. The user must specify expiration date if less than 1 year.

(17) Supervisor's Name (Print Name). The supervisor or representative prints his/her name to indicate that the above information has been verified and that access is required.

(18) Supervisor's Signature. Supervisor's signature is required by the endorser or his/her representative.

(19) Date. Date supervisor signs the form.

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

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

DD FORM 2875 INSTRUCTIONS, APR 2005

INSTRUCTIONS

The prescribing document is as issued by using DoD Component.

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

(21) Signature of Information Owner/OPR. Signature of the functional appointee responsible for approving access to the system being requested.

(21a) Phone Number. Functional appointee telephone number.

(21b) Date. The date the functional appointee signs the DD Form 2875.

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

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

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

(24) Phone Number. IAO's telephone number.

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

(27) Optional Information. This item is intended to add additional information, as required.

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

(28) Type of Investigation. The user's last type of background investigation (i.e., NAC, NACI, or SSBI).

(28a) Date of Investigation. Date of last investigation.

(28b) Clearance Level. The user's current security clearance level (Secret or Top Secret).

(28c) IT Level Designation. The user's IT designation (Level I, Level II, or Level III).

(29) Verified By. The Security Manager or representative prints his/her name to indicate that the above clearance and investigation information has been verified.

(30) Security Manager Telephone Number. The telephone number of the Security Manager or his/her representative.

(31) Security Manager Signature. The Security Manager or his/her representative indicates that the above clearance and investigation information has been verified.

(32) Date. The date that the form was signed by the Security Manager or his/her representative.

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