FI -PLSA 

Over the Counter Channel Application (OTCnet)

Primary Local Security Administrator (PLSA) Authorization Form

The Officer of the Financial Institution identified below designates the following to serve as Primary Local Security Administrator (PLSA) and 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 per Financial Institution.

Section 1 – Request Type

 Create New Financial Institution, 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 Financial Institution, LSA, and/or PLSA:

 Change Financial Institution Name or RTNs 

 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 – Financial Institution Information 

Financial Institution Name: Financial Institution Address (City, State): 

RTN Number(s): CA$HLINK II Account Number(s) (CAN): 

(Please list ALL TGA RTNs) or 

 Account Key(s) (FRBs only):

Do you have multiple processing centers for TGA deposits? Yes No

Section 3 – PLSA Profile 

Each financial institution 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

By signing below the Officer certifies that he/she is duly authorized by the financial institution to designate individuals who can serve as PLSA or LSA. 

The Officer 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