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.)
18. SUPERVISOR'S SIGNATURE17. SUPERVISOR'S NAME
(Print Name)
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. PHON
E 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PREVIOUS EDITION IS OBSOLETE.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)
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DD FORM 2875 (BACK), AUG 2009
PART IV - COMPLETION BY AUTHORIZED STAFF PREPARING ACCOUNT INFORMATION
PROCESSED BY
(Print name and sign)
DATE PROCESS
ED
(YYYYMMDD)
DATE
(YYYYMMDD)
27. OPTIONAL INFORMATION
(Additional information)
SYSTEM
DOMAIN
SERVER
APPLICATION
DIRECTORIES
FILES
DATASETS
TITLE: ACCOUNT CODE
REVALIDATED BY
(Print name and sign)
DATE REVALIDATED
(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
31. SECURITY MANAGER SIGNATURE
29. VERIFIED BY
(Print name)
32. DATE
(YYYYMMDD)
26. NAME
(Last, First, Middle Initial)
LEVEL I LEVEL II LEVEL III
30. SECURITY MANAGER
TELEPHONE NUMBER
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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.
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