Agency -PLSA 

Over the Counter Channel Application (OTCnet)

Primary Local Security Administrator (PLSA) Authorization Form

The Officer of the Agency identified below designates the following to serve as Primary Local Security Administrator (PLSA) and the following to serve

as the Local Security Administrator (LSA) for the Over the Counter Channel (OTCnet) Application. Each PLSA may designate other individuals as Users 

or Local Security Administrators (LSAs). It is required that you have one PLSA and at least one LSA at the Agency/highest level of your 

hierarchy. Section 1 – Request Type

 Create New Agency, PLSA, and LSA Note: The PLSA and LSA User has access to maintain users and user 

permissions for OTCnet in TWAI. PLSA and LSA User does not have access to 

confirm deposits. PLSA and LSAs may have no other OTCnet role

OR

 Modify Agency, LSA, and/or PLSA:

 Change Agency Name or Acronym

 Change PLSA Name 

 (current credentials will be deleted, new credentials will be issued) 

 Current Name: ______________ Current Username: ______________

 Modify PLSA Information (only applies to PLSA’s phone number or address)

 Delete PLSA (attach an authorization form for a new PLSA) 

 Add App Approver Role in SailPoint (this option allows the PLSA or LSA to manage users in SailPoint) 

Section 2 – Agency Information 

Agency Name: 

Agency Acronym: (10 characters maximum) 

Section 3 – PLSA Profile 

Each agency may have only one user designated as a PLSA. 

PLSA’s Name (First and Last)

PLSA’s E-mail Address (not shared)

*Please ensure accuracy – email address is the unique identifier of a

user

Phone Number (direct number to PLSA)

Street Address (PLSA location)

Street Address Line 2 (PLSA location)

City / State / Zip (PLSA location)

PLSA Activation Date (please check one) Activate Immediately Future Activation Date: 

Section 4 – LSA Profile 

Each agency must establish one user as their initial LSA, other LSA’s can be added later. 

LSA’s Name (First and Last)

LSA’s E-mail Address (not shared)

*Please ensure accuracy – email address is the unique identifier of a

user

Phone Number (direct number to LSA)

Street Address (LSA location)

Street Address Line 2 (LSA location)

City / State / Zip (LSA location)

LSA Activation Date (please check one) Activate Immediately Future Activation Date: 

Section 5 – Authorized Signature

The below authorized individual (normally the Director of the Office of Finance, Office of Accounting, or comparable unit) certifies that he/she is duly 

authorized by the agency to designate individuals who can serve as PLSA and LSA. The authorized individual also agrees to be responsible on behalf 

of the institution for all security management related to OTCnet access 

The authorized individual signing this form cannot be designated as a PLSA or LSA on this form. 

Name (print) Signature

Title (required) Phone Date

Authorizing Officer’s E-mail Address (not shared)

*Please ensure accuracy – email address is the unique identifier of a user

Please submit this completed request form to the Treasury OTC Support Center – Information Security.

Please note: The PLSA Form should be emailed to Information Security by the Officer that has signed this form.

Email Address for Information Security – Authorizer must email the form to Information Security

FiscalService.OTCSecurity@citi.com