SYSTEM AUTHORIZATION ACCESS REQUEST (SAAR)
PRIVACY ACT STATEMENT
AUTHORITY: Executive Order 10450, 9397; and Public Law 99-474, the Computer Fraud and Abuse Act.
PRINCIPAL PURPOSE: 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 USES: 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.
TYPE OF REQUEST DATE (YYYYMMDD)
INITIAL MODIFICATION DEACTIVATE USER ID
SYSTEM NAME (Platform or Applications) LOCATION (Physical Location of System)
PART I (To be completed by Requestor)
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 9. DESIGNATION OF PERSON
US FN MILITARY CIVILIAN
OTHER 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 REQUIRED:
AUTHORIZED PRIVILEGED
15. USER REQUIRES ACCESS TO: UNCLASSIFIED CLASSIFIED (Specify category)
OTHER
16. VERIFICATION OF NEED TO KNOW 16a. ACCESS EXPIRATION DATE (Contractors must specify Company Name,
Contract Number, Expiration Date. Use Block 27 if needed.)
I certify that this user requires access as requested.
17. SUPERVISOR'S NAME (Print Name) 18. SUPERVISOR'S SIGNATURE 19. DATE (YYYYMMDD)
20. SUPERVISOR'S ORGANIZATION/DEPARTMENT 20a. SUPERVISOR'S E-MAIL ADDRESS 20b. PHONE NUMBER
21. SIGNATURE OF INFORMATION OWNER/OPR 21a. PHONE NUMBER 21b. DATE (YYYYMMDD)
22. SIGNATURE OF IAO OR APPOINTEE 23. ORGANIZATION/DEPARTMENT 24. PHONE NUMBER 25. DATE (YYYYMMDD)
DD FORM 2875, AUG 2009 PREVIOUS EDITION IS OBSOLETE. Adobe Professional 8.0
26. NAME (Last, First, Middle Initial)
27. OPTIONAL INFORMATION (Additional information)
PART III - SECURITY MANAGER VALIDATES THE BACKGROUND INVESTIGATION OR CLEARANCE INFORMATION
28. TYPE OF INVESTIGATION 28a. DATE OF INVESTIGATION (YYYYMMDD)
28b. CLEARANCE LEVEL 28c. IT LEVEL DESIGNATION
LEVEL I LEVEL II LEVEL III
29. VERIFIED BY (Print name) 30. SECURITY MANAGER 31. SECURITY MANAGER SIGNATURE 32. DATE (YYYYMMDD)
TELEPHONE NUMBER
PART IV - COMPLETION BY AUTHORIZED STAFF PREPARING ACCOUNT INFORMATION
TITLE: SYSTEM ACCOUNT CODE
DOMAIN
SERVER
APPLICATION
DIRECTORIES
FILES
DATASETS
DATE PROCESSED PROCESSED BY (Print name and sign) DATE (YYYYMMDD)
(YYYYMMDD)
DATE REVALIDATED REVALIDATED BY (Print name and sign) DATE (YYYYMMDD)
(YYYYMMDD)
DD FORM 2875 (BACK), AUG 2009 Reset
INSTRUCTIONS
The prescribing document is as issued by using DoD Component.
A. PART I: The following information is provided by the user when (21) Signature of Information Owner/OPR. Signature of the functional
establishing or modifying their USER ID. appointee responsible for approving access to the system being
requested.
(1) Name. The last name, first name, and middle initial of the user.
(21a) Phone Number. Functional appointee telephone number.
(2) Organization. The user's current organization (i.e. DISA, SDI, DoD
and government agency or commercial firm).
(21b) Date. The date the functional appointee signs the DD Form
(3) Office Symbol/Department. The office symbol within the current 2875.
organization (i.e. SDI).
(22) Signature of Information Assurance Officer (IAO) or Appointee.
(4) Telephone Number/DSN. The Defense Switching Network (DSN) Signature of the IAO or Appointee of the office responsible for
phone number of the user. If DSN is unavailable, indicate commercial approving access to the system being requested.
number.
(5)Official E-mail Address. The user's official e-mail address. (23) Organization/Department. IAO's organization and department.
(6) Job Title/Grade/Rank. The civilian job title (Example: Systems (24) Phone Number. IAO's telephone number.
Analyst, GS-14, Pay Clerk, GS-5)/military rank (COL, United States
Army, CMSgt, USAF) or "CONT" if user is a contractor. (25) Date. The date IAO signs the DD Form 2875.
(7) Official Mailing Address. The user's official mailing address. (27) Optional Information. This item is intended to add additional
information, as required.
(8) Citizenship (US, Foreign National, or Other).
(9) Designation of Person (Military, Civilian, Contractor). C. PART III: Certification of Background Investigation or Clearance.
(10) IA Training and Awareness Certification Requirements. User must (28) Type of Investigation. The user's last type of background
indicate if he/she has completed the Annual Information Awareness investigation (i.e., NAC, NACI, or SSBI).
Training and the date.
(28a) Date of Investigation. Date of last investigation.
(11) User's Signature. User must sign the DD Form 2875 with the
understanding that they are responsible and accountable for their (28b) Clearance Level. The user's current security clearance level
password and access to the system(s).
(Secret or Top Secret).
(12) Date. The date that the user signs the form.
(28c) IT Level Designation. The user's IT designation (Level I, Level II,
B. PART II: The information below requires the endorsement from the or Level III).
user's Supervisor or the Government Sponsor.
(29) Verified By. The Security Manager or representative prints his/her
(13). Justification for Access. A brief statement is required to justify name to indicate that the above clearance and investigation
establishment of an initial USER ID. Provide appropriate information if information has been verified.
the USER ID or access to the current USER ID is modified.
(30) Security Manager Telephone Number. The telephone number of
(14) Type of Access Required: Place an "X" in the appropriate box.
(Authorized - Individual with normal access. Privileged - Those with the Security Manager or his/her representative.
privilege to amend or change system configuration, parameters, or
settings.) (31) Security Manager Signature. The Security Manager or his/her
representative indicates that the above clearance and investigation
(15) User Requires Access To: Place an "X" in the appropriate box. information has been verified.
Specify category.
(32) Date. The date that the form was signed by the Security Manager
(16) Verification of Need to Know. To verify that the user requires or his/her representative.
access as requested.
(16a) Expiration Date for Access. The user must specify expiration D. PART IV: This information is site specific and can be customized
date if less than 1 year. by either the DoD, functional activity, or the customer with approval of
the DoD. This information will specifically identify the access required
(17) Supervisor's Name (Print Name). The supervisor or representative by the user.
prints his/her name to indicate that the above information has been
verified and that access is required. E. DISPOSITION OF FORM:
(18) Supervisor's Signature. Supervisor's signature is required by the TRANSMISSION: Form may be electronically transmitted, faxed, or
endorser or his/her representative.
mailed. Adding a password to this form makes it a minimum of "FOR
(19) Date. Date supervisor signs the form. OFFICIAL USE ONLY" and must be protected as such.
(20) Supervisor's Organization/Department. Supervisor's organization FILING: Original SAAR, with original signatures in Parts I, II, and III,
and department. 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
(20a) E-mail Address. Supervisor's e-mail address. IAO. Recommend file be maintained by IAO adding the user to the
system.
(20b) Phone Number. Supervisor's telephone number.
DD FORM 2875 INSTRUCTIONS, AUG 2009
