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 other identifiers 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. ORGANIZATION

3. OFFICE SYMBOL/DEPARTMENT

8. CITIZENSHIP

6. JOB TITLE AND GRADE/RANK

4. PHONE (DSN or Commercial)

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.)

17. SUPERVISOR'S NAME (Print Name) 18. SUPERVISOR'S SIGNATURE 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)

7. OFFICIAL MAILING ADDRESS

5. OFFICIAL E-MAIL ADDRESS

DD FORM 2875, AUG 2009 PREVIOUS EDITION IS OBSOLETE.

USER ID

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

9. DESIGNATION OF PERSON

OTHER

24. PHONE NUMBER

AUTHORITY:

PRINCIPAL PURPOSE:

ROUTINE USES:

DISCLOSURE:

20a. SUPERVISOR'S E-MAIL ADDRESS

US FN

OTHER

MILITARY CIVILIAN

CONTRACTOR

Adobe Designer 9.0

11. USER SIGNATURE 12. DATE (YYYYMMDD)

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

I have completed Annual Information Awareness Training. DATE (YYYYMMDD)
DD FORM 2875 (BACK), AUG 2009

PART IV - COMPLETION BY AUTHORIZED STAFF PREPARING ACCOUNT INFORMATION

DATE PROCESSED PROCESSED BY (Print name and sign)

(YYYYMMDD)

DATE (YYYYMMDD)

27. OPTIONAL INFORMATION (Additional information)

SYSTEM 

DOMAIN 

SERVER 

APPLICATION 

DIRECTORIES 

FILES 

DATASETS 

TITLE: ACCOUNT CODE 

DATE REVALIDATED REVALIDATED BY (Print name and sign)

(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

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

26. NAME (Last, First, Middle Initial)

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) Organization. The user's current organization (i.e. DISA, SDI, DoD

and government agency or commercial firm).

(3) Office Symbol/Department. The office symbol within the current

organization (i.e. SDI).

(4) Telephone Number/DSN. The Defense Switching Network (DSN)

phone number of the user. If DSN is unavailable, indicate commercial

number.

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

(6) 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.

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

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

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

(10) 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.

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

DD FORM 2875 INSTRUCTIONS, AUG 2009

INSTRUCTIONS

The prescribing document is as issued by using DoD Component.

(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.