Form DD2875 System Authorization Access Request

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OMB No. 070X-XXXX
OMB approval expires:
202XXXXX

SYSTEM AUTHORIZATION ACCESS REQUEST (SAAR)

The public reporting burden for this collection of information, 070X-XXXX, is estimated to average XX minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington
Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for
failing to comply with a collection of information if it does not display a currently valid OMB control number.

PRIVACY ACT STATEMENT
AUTHORITY: Executive Order 10450; and Public Law 99-474, the Computer Fraud and Abuse Act
PRINCIPAL PURPOSE(S): 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
ROUTINE USE(S): None.
DISCLOSURE: Disclosure of this information is voluntary; however, failure to provide the requested information may impede, delay or prevent further processing of this request.

DATE (YYYYMMDD)

TYPE OF REQUEST
INITIAL

MODIFICATION

DEACTIVATE

USER ID

SYSTEM NAME (Platform or Applications)

LOCATION (Physical Location of System)

PART I (To be completed by Requester)
1. NAME (Last, First, Middle Initial)

2. ORGANIZATION

3. OFFICE SYMBOL/DEPARTMENT

4. PHONE (DSN or Commercial)

5. OFFICIAL E-MAIL ADDRESS

6. JOB TITLE AND GRADE/RANK

7. OFFICIAL MAILING ADDRESS

8. CITIZENSHIP
US

9. DESIGNATION OF PERSON
FN

MILITARY

OTHER

CIVILIAN

CONTRACTOR

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)

11. USER SIGNATURE

12. DATE (YYYYMMDD)

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.)
13. JUSTIFICATION FOR ACCESS

14. TYPE OF ACCESS REQUESTED
AUTHORIZED

PRIVILEGED

15. USER REQUIRES ACCESS TO:

UNCLASSIFIED

CLASSIFIED (Specify category)

OTHER
16. VERIFICATION OF NEED TO KNOW
I certify that this user requires
access as requested.
17. SUPERVISOR'S NAME (Print Name)

16a. ACCESS EXPIRATION DATE (Contractors must specify Company Name, Contract Number,
Expiration Date. Use Block 21 if needed.)
17a. SUPERVISOR'S EMAIL ADDRESS

17b. PHONE NUMBER

17c. SUPERVISOR'S ORGANIZATION/DEPARTMENT

17d. SUPERVISOR SIGNATURE

17e. DATE (YYYYMMDD)

18. INFORMATION OWNER/OPR PHONE NUMBER

18a. INFORMATION OWNER/OPR SIGNATURE

18b. DATE (YYYYMMDD)

19. IAO ORGANIZATION/DEPARTMENT

19b. IA OR APPOINTEE SIGNATURE

19c. DATE (YYYYMMDD)

19a. PHONE NUMBER

DD FORM 2875, DRAFT 20211103

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20. NAME (Last, First, Middle Initial)
21. OPTIONAL INFORMATION

PART III - SECURITY MANAGER VALIDATES THE BACKGROUND INVESTIGATION OR CLEARANCE INFORMATION
22. TYPE OF INVESTIGATION

23. VERIFIED BY (Printed Name)

22a. CLEARANCE LEVEL

22b. DATE (YYYYMMDD)

24. SECURITY MANAGER 25. SECURITY MANAGER SIGNATURE
TELEPHONE NUMBER

26. DATE (YYYYMMDD)

PART IV - COMPLETION BY AUTHORIZED STAFF PREPARING ACCOUNT INFORMATION
TITLE:

SYSTEM

ACCOUNT CODE

DOMAIN

SERVER

APPLICATION

FILES

DATASETS

DATE PROCESSED (YYYYMMDD)

PROCESSED BY (Print name and sign)
DATE (YYYYMMDD)

DATE REVALIDATED (YYYYMMDD)

REVALIDATED BY (Print name and sign)
DATE (YYYYMMDD)

DD FORM 2875, DRAFT 20211103

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INSTRUCTIONS
The prescribing document is as issued by using DoD Component.

A. PART I: The following information is provided by the user when
establishing or modifying their USER ID.

(18) Phone Number. Functional appointee telephone number.

(1) Name. The last name, first name, and middle initial of the user.

(18a) Signature of Information Owner/OPR. Signature of the functional
appointee responsible for approving access to the system being
requested.

(2) Organization. The user's current organization (i.e. DISA, SDI, DoD and
government agency or commercial firm).

(18b) Date. The date the functional appointee signs the DD Form 2875.

(3) Office Symbol/Department. The office symbol within the current
organization (i.e. SDI).

(19) Organization/Department. IAO's organization and department.

(4) Telephone Number/DSN. The Defense Switching Network (DSN) phone
number of the user. If DSN is unavailable, indicate commercial number.

(19b) 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.

(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.

(19a) Phone Number. IAO's telephone number.

(19c) Date. The date IAO signs the DD Form 2875.
(21) Optional Information. This item is intended to add additional
information, as required.
C. PART III: Certification of Background Investigation or Clearance.

(8) Citizenship (US, Foreign National, or Other).
(9) Designation of Person (Military, Civilian, Contractor).

(22) Type of Investigation. The user's last type of background investigation
(i.e., NAC, NACI, or SSBI).

(10) IA Training and Awareness Certification Requirements. User must
indicate if he/she has completed the Annual Information Awareness
Training and the date.

(22a) Clearance Level. The user's current security clearance level (Secret or
Top Secret).

(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.
(17a) E-mail Address. Supervisor's e-mail address.
(17b) Phone Number. Supervisor's telephone number.

(22b) Date of Investigation. Date of last investigation.
(23) Verified By. The Security Manager or representative prints his/her
name to indicate that the above clearance and investigation
information has been verified.
(24) Security Manager Telephone Number. The telephone number of the
Security Manager or his/her representative.
(25) Security Manager Signature. The Security Manager or his/her
representative indicates that the above clearance and investigation
information has been verified.
(26) 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.

(17c) Supervisor's Organization/Department. Supervisor's organization and
department.
(17d) Supervisor's Signature. Supervisor's signature is required by the
endorser or his/her representative.
(17e) Date. Date the supervisor signs the form.

DD FORM 2875, DRAFT 20211103

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