Dd Form 2875 – Fill Out and Use This PDF

Under TYPE OF REQUEST, mark INITIAL, MODIFICATION or DEACTIVATE USER ID.

Enter the DATE (YYYYMMDD), the SYSTEM NAME (Platform or Applications) and the LOCATION (Physical Location of System).

In 1. NAME, enter the last name, first name, and middle initial of the user.

In 2. ORGANIZATION, enter the user's current organization (i.e. DISA, SDI, DoD and government agency or commercial firm).

In 3. OFFICE SYMBOL/DEPARTMENT, enter the office symbol within the current organization (i.e. SDI).

In 4. PHONE, enter the Defense Switching Network (DSN) phone number of the user; if DSN is unavailable, indicate commercial number.

In 5. OFFICIAL E-MAIL ADDRESS, enter the user's official e-mail address.

In 6. JOB TITLE AND GRADE/RANK, enter 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.

In 7. OFFICIAL MAILING ADDRESS, enter the user's official mailing address.

In 8. CITIZENSHIP, mark U.S., Foreign National, or Other.

In 9. DESIGNATION OF PERSON, mark Military, Civilian, Contractor.

In 10. IA TRAINING AND AWARENESS CERTIFICATION REQUIREMENTS, complete as required for user or functional level access: the user must indicate if he/she has completed the Annual Cyber Awareness Training and the date.

In 11. USER SIGNATURE, the 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).

In 12. DATE (YYYYMMDD), enter the date that the user signs the form.

PART II: the information requires the endorsement from the user's Supervisor or the Government Sponsor.

In 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.

In 14. TYPE OF ACCESS REQUESTED, place an "X" in the appropriate box: Authorized is an individual with normal access, and Privileged is those with privilege to amend or change system configuration, parameters, or settings.

In 15. USER REQUIRES ACCESS TO, place an "X" in the appropriate box (UNCLASSIFIED, CLASSIFIED or OTHER) and specify category for CLASSIFIED.

Under 16. VERIFICATION OF NEED TO KNOW: "I certify that this user requires access as requested."

In 16a. ACCESS EXPIRATION DATE, the user must specify expiration date if less than 1 year.

If the individual is a contractor, provide company name, contract number, and date of contract expiration in Block 16.

Contractors must specify Company Name, Contract Number, Expiration Date for 16a. ACCESS EXPIRATION DATE; use Block 21 if needed.

In 17. SUPERVISOR'S NAME (Print Name), the supervisor or representative prints his/her name to indicate that the information has been verified and that access is required.

In 17a. SUPERVISOR'S EMAIL ADDRESS, 17b. PHONE NUMBER and 17c. SUPERVISOR'S ORGANIZATION/DEPARTMENT, enter the supervisor's e-mail address, telephone number, and organization and department.

In 17d. SUPERVISOR SIGNATURE, the supervisor's signature is required by the endorser or his/her representative; in 17e. DATE (YYYYMMDD), enter the date the supervisor signs the form.

In 18. INFORMATION OWNER/OPR PHONE NUMBER, enter the functional appointee telephone number.

In 18a. INFORMATION OWNER/OPR SIGNATURE, the Information Owner or functional appointee of the office responsible for approving access to the system being requested signs; in 18b. DATE (YYYYMMDD), enter the date the functional appointee signs the DD Form 2875.

In 19. ISSO ORGANIZATION/DEPARTMENT and 19a. PHONE NUMBER, enter the ISSO's organization and department and the ISSO's telephone number.

In 19b. ISSO OR APPOINTEE SIGNATURE, the ISSO or Appointee of the office responsible for approving access to the system being requested signs; in 19c. DATE (YYYYMMDD), enter the date the ISSO or Appointee signs the DD Form 2875.

21. OPTIONAL INFORMATION is intended to add additional information, as required.

Part III - Security Manager validates the background investigation or clearance information: in 22. TYPE OF INVESTIGATION, the user's last type of background investigation (i.e., Tier 3, Tier 5, etc.); in 22a. INVESTIGATION DATE, the date of last investigation.

In 22b. CONTINUOUS EVALUATION (CE) DEFERRED INVESTIGATION, select yes/no to validate whether or not the user is currently enrolled for "Deferred Investigation" in the Continuous Evaluation (CE) program.

In 22c. CONTINUOUS EVALUATION (CE) ENROLLMENT DATE, enter the date of CE enrollment; leave blank if user is not enrolled in CE.

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, and it will specifically identify the access required by the user.

TRANSMISSION: Form may be electronically transmitted, faxed, or mailed. 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 ISSO; recommend file be maintained by ISSO adding the user to the system.