**Section A. [USER INFORMATION]{.underline}**

Check appropriate box. For employees of Guaranty Agencies, Lenders, or
Servicers, do NOT check a box. Instead complete the statement in the
"Additional Comments" area with the name and ID of the Guaranty Agency,
Lender, or Servicer.

**Name** -- User's name for whom the request is made.

**User** - (new, delete, change access, renew access) normally, check
the New User space. In the event that your situation changes and you no
longer require access to the system, you are required to contact the
System Security Officer in writing. When this occurs, you should check
the 'Delete User' space.

**Last four digits of SSN** - The last four digits of the user's social
security number.

**Current User ID** (if any) --Note any Department of Education userid
that the requestor currently has.

**Phone**: - Work telephone number where user may be contacted.

**Short Description of Task (REQUIRED)** -- Provide a short description
of your task within your organization that requires that you have access
to the FP Data Mart.

System Security Officer or Alternate to be notified when access is
completed. (Must

be ED employee): - (this information is pre-filled on the form -- do NOT
modify)

Willie M. Sutton, <willie.sutton@ed.gov>, 202-377-3320

Brenda Ware, <brenda.ware@ed.gov>, 202-377-3319

Section B. [TYPE OF ACCES REQUESTED]{.underline}

System Matrix - This information is pre-filled on the form -- do NOT
modify

Application Manager Name -- Rich Ryan

Application -- Financial Partners Data Mart

System Name -- FPM (for production data mart)

Prod Level -- Prod (for production data mart)

Access type -- User

System Type -- blank

Comments - ORACLE

**Additional Comments: -** For Department of Education employees -
provide information to identify office of assignment (ex. FSA -
Financial Partners Channel/Partner Services). For non-Department of
Education employees -- provide information related to your organization.
For all requests, the requestor may also note any other information that
supports the request.

Disregard the section referencing the risk level.

1.  **Applicant:** - Requester (user) prints and signs name, and date.

2.  **Applicant Supervisor**: - Supervisor prints and signs name, and
    date.

3.  **SSO, ED Project Mgr, or COTR:** - Do not enter. This is for FSA
    office use only.

Section C. [FSA Personnel Security Office Use Only]{.underline}

This section is for FSA office use only. Do not modify.

Section D. [Privacy Act]{.underline}

Read the Privacy Act information and sign to indicate your agreement.

Section E. [Signature]{.underline}

Complete all information in this section

Section F. [For Office Use Only]{.underline}

This section is for FP office use only. Do not modify.

Mail the originals of the completed and signed form to the following
address (NOTE: electronically submitted forms will NOT be accepted):

U.S. Department of Education

Federal Student Aid

Financial Partners Data Mart

830 1^st^ Street NE

Washington, DC 20002

Attn: Willie Sutton

If you have any questions regarding this security packet, please
contact:

> Willie Sutton 1-202-377-3320
> [Willie.Sutton@ed.gov](mailto:Fms_operations@ed.gov)

+-------------------+--------------------------------------------------+
| ![](              | # DEPARTMENT OF EDUCATION                        |
| media/image1.wmf) |                                                  |
|                   | ## FEDERAL STUDENT AID (FSA)                     |
|                   |                                                  |
|                   | ###### User ID Request Form                      |
|                   |                                                  |
|                   | ####                                             |
|                   | # This Document Contains Privacy Act Information |
+-------------------+--------------------------------------------------+

  -------------------- -------------------- ----------------------------------------------------------------
  A. USER INFORMATION  \_\_\_\_\_ED         \_\_\_\_\_\_Contractor (List Company Name)
                       employee             \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  -------------------- -------------------- ----------------------------------------------------------------

Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**\_\_\_X\_** New User

Last Four Digits of SSN: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_ Delete User

Current User ID (if any)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_ Change/ Expand Access

Phone:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_ Renew Access

Short Description of Task (**REQUIRED**): **System Security Officer or
Alternate to be notified when access is completed. (FSA SSO)**:

Name [Willie M.
Sutton]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ [Email
address:]{.underline} <willie.sutton@ed.gov>
Telephone_202-377-3320\_\_\_\_\_

Alternate (SSO): Name: [Brenda
Ware]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_Email Address:
[Brenda.ware@ed.gov]{.underline}\_Telelphone_202-377-3319\_\_\_\_

  -------------------------- --------------------------------------------
  B. TYPE OF ACCESS REQUIRED **Must Include Exact Information from Matrix
                             To Match Headings or cut and paste directly
                             from the matrix**

  -------------------------- --------------------------------------------

VDC Application Access type

####### **Manager (Name)** SFA Application VDC System Name Prod Level (User/Dev/DBA) System Type Comments

  ---------- ----------- ----------- ------------ --------- --------- ---------
  Rich Ryan  Financial   FPM         Production   User                ORACLE
             Partners                                                 
             Data Mart                                                

  ---------- ----------- ----------- ------------ --------- --------- ---------

Additional Comments:

I am an employee of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
whose GA ID, Lender ID, or Servicer ID number is
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

I am a Department of Education employee and I work in the Office of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. Within that Office, I am in
the
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

System Security Access Controls require a clearance at one of the listed
risk levels to be met. The applicant has submitted all required forms to
SFA Personnel Security for clearance at this level.

*Check One* (**SSO is** **Required to Select**)

\_\_\_\_\_\_Low Risk, **1C** (SF-85, OF-306, Fingerprints)

\_\_\_\_\_\_Moderate Risk, **5C** (SF-85P, OF-306, Credit Release,
Fingerprints)

\_\_\_\_\_\_High Risk, **6C** (SF-85P, OF-306, Credit Release, 85P-S,
Fingerprints)

1\. Applicant:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date\_\_\_\_\_\_\_\_

*Print Name Signature*

2\. Applicant Supervisor:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*\_*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date\_\_\_\_\_\_\_\_

*Print Name Signature*

3\. SSO, ED Project Mgr, or COTR:
\_\_\_\_\_\_\_\_*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*
Date\_\_\_\_\_\_\_\_

Print Name Signature

  -----------------------------------------------------------------------
  **C. FSA Personnel Security Office Use Only**

  -----------------------------------------------------------------------

Approval\_\_\_JOEL CLARK\_\_\_\_Rm 22B2\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date:
\_\_\_\_\_\_\_\_\_\_\_ *Print Name Signature*

Current Security Status: In Progress Level\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date Security Packet Forwarded to FSA HR: \_\_\_

D. Privacy Act

\(i\) (1) Criminal penalties

> Any officer or employee of an agency, who by virtue of his employment
> or official position, has possession of, or access to, agency records
> which contain individually identifiable information the disclosure of
> which is prohibited by this section or by rules or regulations
> established thereunder, and who knowing that disclosure of the
> specific material is so prohibited, willfully discloses the material
> in any manner to any person or agency not entitled to receive it,
> shall be guilty of a misdemeanor and fined not more than \$5,000.
>
> \(2\) Any officer or employee of any agency who willfully maintains a
> system of records without meeting the notice requirements of
> subsection(e)(4) of this section shall be guilty of a misdemeanor and
> fined not more than \$5,000.
>
> \(3\) Any person who knowingly and willfully requests or obtains any
> record concerning an individual from an agency under false pretenses
> shall be guilty of a misdemeanor and fined not more than \$5,000.

I have read this information, and I agree to the terms.

Applicant Signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  -----------------------------------------------------------------------
  E. SIGNATURES

  -----------------------------------------------------------------------

Applicant:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_\_\_\_\_

#########  Signature

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

#########  Printed Name

Applicant Supervisor:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_\_\_\_\_

#########  Signature

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

#########  Printed Name

  -----------------------------------------------------------------------
  F. FOR OFFICE USE ONLY

  -----------------------------------------------------------------------

FP Security Officer:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date\_\_\_\_\_\_\_\_\_\_\_\_\_

#########  Signature

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

#########  Printed Name