Shared Accounting Module (SAM)

Agency User Authorization Form

The User listed is designated to perform the Role and Access Group responsibilities in the Shared Accounting Module (SAM) in 

accordance with the SAM Security Matrix. 

Section 1 – General Information

 Create New User

 Modify User Information (only applies to role, last name, e-mail address, phone number and/or address)

 Delete User

Add Remove Role

 Local Security Administrator 

 Cash Flow Administrator (User has access to Access Group Cash Flow Profiles, Default Rules and related reports.)

 Agency Viewer (User has view-only access of Cash Flow Profiles, Default Rules and related reports.)

Primary Access Group 

Descendant Access Group 

______________________________________________________________

Enter the name of Access Group to which the user will have access.( A maximum of 50 alpha 

numeric characters) An Access Group is a group created to relate ALC(s) or DSSN(s) in terms of 

security and business commonality.

Section 2 – User Profile 

User’s Employer /Agency/Bureau

User’s Name (Full name) 

User’s E-mail Address (Not shared)

*Please ensure accuracy – email address is the

unique identifier of a user

Phone Number (Direct number to user) 

Street Address (User location)

Street Address Line 2 (User location)

City / State / Zip (User location)

User Activation Date (Please check one) Effective Immediately Future Effective Date 

Section 3 – Authorized Signature By signing below, the individual certifies that he/she is duly authorized by the organization under the

Shared Accounting Module (SAM) Primary Local Security Administrator (PLSA) Authorization Form to perform the changes requested. The authorized 

individual will be contacted and must confirm signature before the request can be completed. The authorized individual signing this form cannot be 

designated as the user on this form.

Name (print) Signature

Title Phone Date

Email Address

Please email the completed form to the SAM Treasury Support Center: SAM_TSC@stls.frb.org 
Section 4 – Additional Access Groups to which the user will have access

Primary Access Group Descendant Access Group 

Access Group Name:____________________________________________________

Enter the name of the specific Access Group to which the user is to have access.

Primary Access Group Descendant Access Group 

Access Group Name:____________________________________________________

Enter the name of the specific Access Group to which the user is to have access.

Primary Access Group Descendant Access Group 

Access Group Name:____________________________________________________

Enter the name of the specific Access Group to which the user is to have access.

Primary Access Group Descendant Access Group 

Access Group Name:____________________________________________________

Enter the name of the specific Access Group to which the user is to have access.

Primary Access Group Descendant Access Group 

Access Group Name:____________________________________________________

Enter the name of the specific Access Group to which the user is to have access.

Primary Access Group Descendant Access Group 

Access Group Name:____________________________________________________

Enter the name of the specific Access Group to which the user is to have access.

Primary Access Group Descendant Access Group 

Access Group Name:____________________________________________________

Enter the name of the specific Access Group to which the user is to have access.

Primary Access Group Descendant Access Group 

Access Group Name:____________________________________________________

Enter the name of the specific Access Group to which the user is to have access.